Reddy et al.: OCD in India 31 An overview of Indian research in obsessive compulsive disorder
Y. C. Janardhan Reddy, Naren P. Rao, Sumant Khanna
ABSTRACT
Obsessive-compulsive disorder (OCD) was considered a relatively rare disorder until about two decades ago. Since then, considerable advance has been made in understanding the various aspects of OCD that include epidemiology, clinical features, comorbidity, biology and treatment. In the last one decade, there has also been interest in a group of related disorders called obsessive-compulsive spectrum disorders. There is substantial research from India on various aspects of OCD, particularly from the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore. We attempt to review all the relevant Indian data on OCD.
Key words: OCD, Research, India
ADULT OBSESSIVE-COMPULSIVE DISORDER
Epidemiology
There is only one epidemiological study from India.[1] The study found lifetime prevalence of 0.6%. This rate is considerably lower compared to the 2- 3% rate reported in the European and North American studies.[2,3] However, similar low rate ranging from 0.5-0.9% was observed in a study from Taiwan.[4] It is not clear why lifetime prevalence rate of OCD is lower in some countries although the rates are not very low compared to the conservative estimate of 1% rate of OCD.[5] However, further research is needed into the epidemiological aspects of OCD in India since the data available is limited.
Phenomenology of obsessive-compulsive disorder in adults
Phenomenology has been an important area of research in the field of OCD that has attracted the attention of Indian researchers. The earliest such study was by Dutta Ray in 1964[6] followed by a series of articles by Akhtar et al. on phenomenology and socio-cultural determinants of symptoms in OCD,[7-9] Chakraborty and Banerji, in a study that compared 200 "obsessionals" with 200 controls reported a high rate of family history of obsessional illness (26%) and premorbid obsessional personality (26%).[10] Two other studies also reported high rates of obsessive personality.[11,12]
Khanna et al. in an exploratory study examined whether a reactive- endogenous dichotomy exists.[13] Acute onset and fluctuating course was significantly commoner in the reactive subgroup. In an attempt to clarify the nosological status of OCD, Gojer et al. compared 53 cases of OCD with an equal number of subjects with depression and anxiety neurosis.[14] There were more similarities in the OCD and anxiety neurosis group than the depressive group.
Khanna and Channabasavanna developed a classificatory system for obsessions and compulsions based on form and content.[15,16] Obsessions were categorized into six categories of form and twelve categories of content and compulsions in to four categories of form and eight categories of content. In the same sample of patients, phenomenology was analyzed using cluster analysis.[17] Four reliable clusters were derived using variables present in 10-90% of the subjects: Washing, checking, thoughts of past and embarrassing behavior. Depression occurred as a unique cluster. Subtypes of OCD were also examined in the same sample.[18] The study showed that washers and checkers are valid subtypes of OCD.
In another study,[19] 222 consecutive subjects were evaluated using the Yale- Brown Obsessive-Compulsive Scale (Y-BOCS) symptom checklist[20] and the Scale for Assessment of Form and Content (SFC).[21] The data was subjected to factor analysis with varimax rotation. The main factors that emerged were washers, checkers, hoarding and two pure obsession factors. The obsession groups had a preponderance of sexual and religious themes. The findings are largely in concordance with those of studies from other parts of the world suggesting similarity across cultures.[22,23] The study, however, supports separating obsessions from compulsions because two pure obsession factors emerged, which is in keeping with the findings of the two previous studies.[24,25] Three recent studies of OCD in adults have also used the Y- BOCS to measure obsessive-compulsive symptoms.[19,26-28] The phenomenology of OCD in these studies is similar to that described in the western population.[29]
Jaisoorya et al. examined gender differences in OCD. [30] Males had an early onset of OCD, and had a higher prevalence of symmetry/religious obsessions, miscellaneous compulsions, and comorbid attention deficit hyperactivity disorder (ADHD). Females had higher prevalence of cleaning compulsions and comorbid trichotillomania.
Kamath et al. examined suicidal behavior in 100 consecutive DSM-IV OCD patients;[28] 59% had 'worst ever' (lifetime) suicidal ideation and 28% had current suicidal ideation. History of suicidal attempt was reported in 27% of the subjects. Major depression, unmarried status and hopelessness were the major risk factors for suicidal behavior.
Gururaj et al. assessed the family burden, quality of life and disability in OCD patients and compared them with patients with schizophrenia of comparable severity.[31] Patients with schizophrenia had higher family burden but were comparable to OCD patients with respect to quality of life and disability. The study showed that OCD patients were associated with significant disability, poor quality of life and high family burden comparable to schizophrenia.
Insight into obsessive-compulsive disorder
Traditionally, OCD is described as a condition in which patients have good insight into their symptoms. The DSM- IV field trial demonstrated a broad range of insight with 30% having poor insight.[32] Subsequent studies have also reported poor insight in 15-36% of patients with OCD. [33- 36] The DSM- IV has added a new OCD specifier: "With poor insight" which involves a lack of recognition that the symptoms are unreasonable or excessive.[37]
There is paucity of data regarding the clinical correlates and treatment response of poor insight in OCD. A significant limitation of most of the studies is that they did not use validated measure of insight. Only one study[33] used the Brown Assessment of Beliefs Scale (BABS) developed specifically to assess insight.[38] In a recent Indian study, demographic and clinical correlates of poor insight OCD, and the association between response to specific serotonin reuptake inhibitors (SSRIs) and baseline insight was examined in a sample of 100 DSM-IV OCD subjects by using the BABS as a measure of insight.[27] The sample had 25 subjects with poor insight and the remaining 75 had good insight. Those with poor insight had earlier age-at-onset, more severe illness, higher comorbidity rate particularly major depression, over representation of miscellaneous obsessions and hoarding and poorer treatment response. The study suggests that OCD with poor insight could be a distinct subtype. That a significant proportion of OCD patients have poor insight has important treatment implications. Patients with poor insight could easily get misdiagnosed as psychotic and treated accordingly. The study suggests that drug treatment response is poor in those with poor insight. The finding is in sharp contrast to the findings of a previous study that reported that degree of insight at baseline did not predict response to sertraline. [33] It is clinically pertinent to examine if poor insight patients do better with addition of neuroleptics. There is, however, no evidence as yet to suggest that those with poor insight respond better to augmentation with antipsychotics. On the other hand, a few studies have shown that insight improves after treatment with SSRIs.[35,36]
Comorbidity
Studies of comorbidity are varied and have examined a broad range of topics including spectrum disorders, comorbidity with schizophrenia and bipolar disorder and even prevalence of OCD in Parkinson's disease.
Obsessive-compulsive (OC) spectrum disorders have over the past few years emerged as a unique and fascinating category of related conditions.[39] Jaisoorya et al. examined the prevalence of putative OC spectrum disorders in a large sample of OCD subjects (n 5 231) in comparison with relatives of neurologically ill patients (n 5 200).[26] Prevalence of tic disorders (39% vs. 12%), hypochondriasis (13% vs. 0), BDD (3% vs. 0) and trichotillomania (3% vs. 0) were significantly greater in OCD subjects compared to controls. However, the prevalence of sexual compulsions, pathological gambling, eating disorders, and depersonalization disorder was not greater in the OCD subjects compared to controls. The findings of this study suggest that tic disorders, hypochondriasis, BDD, and trichotillomania are perhaps part of the OC spectrum disorders. The evidence for exclusion of other disorders from the hypothesized OC spectrum is not conclusive because of the rarity of the occurrence of some of these disorders in the study sample. The findings are somewhat similar to those of a study that reported high rates of BDD, hypochondriasis and low rate of eating disorders and most impulse control disorders other than pathological skin picking.[40] Only one patient in the sample had an eating disorder. The finding is in sharp contrast to a previous study that reported high rates of eating disorders among OCD patients.[41]
This divergence should be viewed in the light of the rare reporting of eating disorders in Asian countries[42,43] but could well be a correlate of cultural beliefs and attitudes that have been identified as significant contributing factors in the development of eating disorders.[43] Jaisoorya et al. examined the differences between tic related and non tic related OCD with respect to sociodemographics, symptom profile, and comorbidity.[44] Tic related OCD had an early age at onset, over representation of males, aggressive obsessions, cleaning compulsions and comorbid trichotillomania.
In a chart review of comorbidity in 218 OCD subjects, 17% had major depression, 6% dysthymia, and 7% any anxiety disorder.[45] Comorbidity rates were low and there were not many differences between those with and without comorbidity except that female subjects were more likely to have depression. Kalra et al. compared OCD with and without comorbid Axis I disorders in a sample of 54 subjects and found that those with comorbidity had higher scores on depression and OCD severity scales.[46] The study findings were in tune with earlier literature from rest of the world. Gupta et al. examined level of comorbid depression in patients with OCD, psychotic depression and chronic medical illness.[47] All three groups had moderate to high levels of depression, with OCD group intermediary between psychotic depression and physical illness. However, the OCD group had more life events than depression or physical illness.
Rajkumar et al.[48] studied the clinical profile of schizophrenic patients with and without comorbid OCD (50 in each group). Schizo-obsessive patients had higher rates of paranoid symptoms and first-rank symptoms of schizophrenia. They had lower anergia, higher depression scores, more comorbid personality disorders, and disability. Significant correlations were observed between OCD severity scores and schizophrenia symptom dimension scores. Authors concluded that "schizo-obsessive" schizophrenia may be a distinct subtype with unique clinical characteristics.
A retrospective chart analysis of 15 cases OCD with psychosis found that obsessive doubts, washing and checking compulsions were the most common OC symptoms.[49] Twelve cases had a diagnosis of schizophrenia, while three had atypical psychosis. About half the patients had First Rank symptoms of schizophrenia. Nearly three-fourth of the sample showed significant improvement on treatment with a combination of antipsychotic and antiobsessional drugs.
Zutshi et al.[50] examined differences between bipolar OCD and non-bipolar OCD. Bipolar OCD was associated with episodic course, a higher family loading for mood disorders, and higher rates of comorbid depression, social phobia and generalized anxiety disorder. In majority of the patients, OCD predated bipolar disorder and OCD worsened during depression and improved during mania. Authors concluded that OCD in those with bipolar disorder may be pathophysiologically related to bipolar disorder.
Harbishettar et al.[51] systematically assessed OC symptoms and OCD in 69 Parkinson's disease patients and matched medically ill controls. There was no difference between the groups with respect to OC symptoms, OCD both clinical and subclinical and tics. Also, there was no relationship between severity of Parkinson's disease and OC symptoms. Authors speculated that different circuitry may be involved in the pathophysiology of OCD and Parkinson's disease although basal ganglia involvement may be common to both the disorders. Course and outcome
There is limited literature on the long-term course and outcome of OCD. In an 11-13 year follow-up study of 75 subjects with OCD, Reddy et al.[52] reported a favorable outcome in majority of the subjects: 43% had no OCD, 33% had subclinical OCD and only 24% had clinical OCD. Median time to reach 'no OCD' and 'subclinical' status was 42 months and 84 months respectively. Interestingly, 37% were in true remission ('no OCD' and not on any treatment) for a median period of 132 months. Those who had 'mixed' OCD and Axis I comorbidity had poorer outcome. Age of onset and duration of illness had no effect on outcome. Optimistic outcome reported in this study is somewhat different from the findings of studies from other parts of the world which have reported lower rates of remission. Previous studies included samples that were severe and chronically ill with high rates of comorbidity. The subjects in the study by Reddy et al. were largely self-referred, moderately ill, and did not have history of treatment resistance. The findings of this study, therefore, could be generalized for patients routinely seen in the outpatient consultation at clinics and secondary-care hospitals in India.
Math et al.[53] in another follow-up study explored if the long term outcome of 'predominantly obsessive' subjects differs from that of 'mixed' OCD. They studied the five to six-year course and outcome of 54 patients with 'predominantly obsessions' and 54 with 'mixed' subtype of OCD. The course of the illness was similar in both and a majority (72%) did not have clinical OCD at follow up.
In another study, Shetti et al.[54] examined the differences between SSRI responders and non responders. They assessed 67 SRI responders and 55 non responders. Base line severity of illness, comorbid major depression, sexual obsessions, washing and miscellaneous compulsions, early age at onset, 'mixed' OCD and poor insight were associated with poor response to SRIs.
NEUROBIOLOGY
Neurotransmitters in obsessive-compulsive disorder
A serotonergic hypothesis of OCD was suggested originally by the observed differential efficacy of SRIs in alleviating OCD symptoms.[55] Since then, numerous studies of peripheral receptor binding in the blood or concentrations of serotonin metabolites in cerebrospinal fluid have been performed but have yielded inconsistent results.[56] Pharmacological challenge studies provide another indirect approach. By administering serotonergic agents and measuring endocrine and behavioral responses, investigators have attempted to study the central serotonergic functioning in OCD. It is observed that OCD patients become significantly more anxious and dysphoric after administration of meta- chlorphenyl-piperazine (mCPP), a 5- HT receptor agonist.[55] In addition, obsessive-compulsive symptoms worsen. However, there appears to be blunted cortisol and prolactin response in response to mCPP. In an attempt to replicate these findings, mCPP was administered orally in a randomized double-blind design to 34 OCD patients who were either drug-naïve or drug-free for a minimum of four weeks.[57] The cortisol and prolactin responses were contrasted with those of 18 drug-free healthy subjects. The OCD patients showed significantly blunted cortisol and prolactin responses to mCPP challenge as compared to normal subjects. However, mCPP did not produce any significant exacerbation of obsessive-compulsive symptoms in the patients. These findings are suggestive of a serotonin (5- HT) receptor hyporesponsivity in the HPA axis. Even though previous studies indicate a hyperresponsivity of the 5- HT receptor system as shown by significant symptom worsening following serotonergic challenge,[58,59] the Indian study failed to replicate those results.[58] It was postulated that the 5-HT receptor hyporesponsivity in the HPA axis may be a biological "trait marker" of OCD, and may not be directly involved in the mediation of symptomatology of the disorder. It could also be inferred that the discrepancy among studies regarding the behavioural responses to mCPP challenge may in part be due to differences in the basic environmental conditions across various studies.[60] In a previous study by the same group, an endocrinological blunting in the absence of a behavioural increase in obsessive-compulsive symptoms was documented after oral administration of mCPP; however, when exposure was incorporated into the paradigm, with oral mCPP, exacerbation of obsessive-compulsive symptoms was noted.[61]
A normal endocrinological response after treatment with clomipramine was also independently documented. [62] It is a matter of conjecture whether stimulation of noradrenergic system by the alpha2 adrenergic antagonistic action of mCPP, or behavioral exposure conditions during the challenge procedure are also partly responsible for the symptom exacerbation as noted in previous studies.[57]
In summary, pharmacological challenge studies and other studies that have explored serotonergic hypothesis in OCD, have very limited evidence to support a primary serotonergic dysfunction in OCD.[63] However, a modulation of serotonergic system clearly plays a role in effective pharmacotherapy of at least a significant proportion of OCD patients.
In a study by Khanna et al. there was a blunted growth hormone, cortisol and ACTH response to clonidine in OCD. [64] On qualitative analysis three possible responses of growth hormone were obtained: Accentuation (.10 ng/ ml), normal (5-10 ng/ml) and attenuation (,10 ng/ml). Most patients with an accentuated response were patients with compulsions, pure obsessions were significantly more likely to have blunted responses. The study findings suggest noradrenergic dysfunction in OCD and also imply noradrenergic heterogeneity in the observation that pure obsessions tend to have a more down regulated noradrenergic system as compared to the compulsives. Based on their work, Khanna et al. concluded that serotonergic hypothesis may not explain all the abnormalities seen in OCD and that complex interactions between various neurotransmitters as well as the environmental conditions may be necessary to cause OCD.[57]
Soft neurological signs
Thirty-seven drug free non-depressed OCD subjects and 20 normal healthy volunteers were screened for SNS.[65] The OCD subjects had significantly more total SNS as compared to normals. These findings were most marked in the frontal lobe functions. There was a trend towards significance in temporal lobe functions, while other test findings were not impaired. If individual items were studied the problems were predominantly in complex motor tasks. There was no significant laterality effect.
Electrophysiological studies
Most electrophysiological studies in OCD have either tried to localize the site of the disorder at a structural or functional substrate, or have been based on the associated increased autonomic arousal. Khanna concluded that in most cases there was no obvious EEG abnormality in OCD; when it was present it was likely to be a non-specific disturbance in the temporal and frontotemporal regions.[66]
In OCD there was a decreased power in the nondominant frontomedial and posterior temporal regions in the computerized EEG analysis. There were no significant differences in the coherence observed from these sites. [67] The study suggested nondominant frontomedial hypofunctioning to be associated with OCD.
In a study of resting middle latency auditory and visual evoked potentials in 50 OCD subjects and 40 normal controls, there were no significant differences between the two groups for amplitude and latency or left-right ratios. [68] The study did not support any laterality deficit in OCD and was inconsistent with the hypothesis of left frontal lobe dysfunction in OCD.[69] A more prolonged post imperative negativity and a higher amplitude of the late component of the Contingent Negative Variation (CNV) has been repeatedly recorded.[66] OCD patients exhibited higher amplitude of the 'late' component of the CNV. The role of the mesencephalic reticular formation with modulation by the frontal granular cortex in the genesis of these potentials has been stressed.
Bereitschafts potential has been found absent or to have a decreased onset latency in 44 subjects with OCD.[70] A deficit of the complex motor programming circuit similar to those observed in Gilles de la Tourette syndrome has been put forth on the basis of this observation.[70] Based on the evidence from electrophysiological, neuropsychological, scan, lesion, and psychosurgical studies, Khanna also proposed an integrated model of possible frontal dysfunction in OCD with associated dysfunction in other areas of the brain such as cingulum and basal ganglia.[66]
Immunological factors
Khanna et al. documented increased levels of serum immunoglobulins in OCD subjects as compared to normal controls, with specific reference to IgG.[71] The IgG levels were high even after clinical improvement. The authors speculated that the immunological abnormality could be a marker of vulnerability to OCD. They also discussed the possibility that the immunological dysfunction could be due to an unidentified infectious agent or an autoimmune process. As an extension of the hypothesis, viral antibodies were measured in the blood[72] and cerebrospinal fluid (CSF) of OCD subjects.[73] IgG viral antibodies for herpes simplex virus-1 (HSV-1), varicella zoster, cytomegalo virus, measles and mumps were studied in 76 subjects with OCD and compared with 55 normal healthy volunteers. There was a significantly higher titer for HSV-1 antibodies in both serum and CSF. The sera: CSF ratios were suggestive of intrathecal synthesis. The study on viral antibodies in CSF suggests a role for HSV-1 in OCD. However, caution needs to be exercised in interpreting the finding because of certain methodological issues raised in the paper by the authors.
Exploration of the contribution of immunological mechanisms in the manifestation of OCD continued in a recent study by Bhattacharya et al. that investigated the presence of auto antibodies directed against the basal ganglia or thalamus in the serum as well as CSF of 23 OCD patients compared with 23 matched psychiatrically normal controls using western blot.[74] They further investigated CSF amino acid (glutamate, GABA, taurine, and glycine) levels and examined the extent to which these levels were related to the presence of auto - antiibodies. There was evidence of significantly more binding of CSF auto - antiibodies to homogenate of basal ganglia as well as to homogenate of thalamus among OCD patients compared to controls. There was no significant difference in the pattern of binding between patients and controls using serum. CSF glutamate and glycine levels were also significantly higher in OCD patients compared with controls, and CSF glycine levels were also significantly higher in those OCD patients who had auto - antiibodies compared to those without. The study implicates autoimmune mechanisms in the pathogenesis of OCD and also provides preliminary evidence that auto antobodies against basal ganglia and thalamus may cause OCD by modulating excitatory neurotransmission.
In support of the possible immunological mechanisms in the causation of at least some forms of OCD, a few clinical studies have examined the association between infections and OCD. A study reported OCD in some cases of Herpes Simplex encephalitis.[75] In a study of 20 subjects with rheumatic chorea, four subjects (20%) had OCD. [76] The relationship between OCD and rheumatic chorea and Pediatric, Autoimmune, Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) is well known.[77] Considering the association between rheumatic fever and OCD, and possible long term neuropsychiatric sequelae in those with history of rheumatic fever because of possible autoimmune insult to basal ganglia, a study recently examined the prevalence of OCD in adults with Rheumatic Heart Disease (RHD).[78] Of the 100 subjects with RHD, 10 had clinical OCD. This rate is at least five-fold higher than the reported global general population rate of OCD[5] and over 15-fold higher than the 0.6% rate of OCD in India.[1] The finding lends support to the hypothesis that OCD could be a long term complication of autoimmune basal ganglia insult in childhood just as RHD is a long term sequel of autoimmune damage to the heart. The results of this study need to be replicated in a controlled study.
Chakrabarty et al. investigated glutamatergic dysfunction linked to immune pathogenesis in 21 OCD patients and 18 healthy controls by collecting CSF.[79] They estimated glutamate levels and found that OCD patients had higher glutamate levels. Age, gender, duration of illness, severity of illness did not have any effect on glutamate levels.
NEUROPSYCHOLOGY
Neuropsychological studies have provided important clues in understanding the neurobiological basis of OCD. As neuropsychological deficits are potential endophenotype markers, studies have examined patients in symptomatic phase, recovered phase and also in unaffected first degree relatives.
Trivedi et al.[80] examined executive functions, vigilance and spatial working memory in 30 OCD patients and 30 age and education matched control subjects. OCD patients had significant deficits in all the cognitive domains. There was a positive correlation between severity of illness and attention deficits but there was no correlation between duration of illness and cognitive dysfunction. A study by Tarafder et al.[81] examined neuropsychological disposition and executive functions in 20 OCD patients and 20 matched normal healthy controls. Subcortical-cerebellar-spinal domain was found to be associated with cognitive style and executive functions, affirming the neurobiological basis of the disorder.
Rao et al. examined neuropsychological deficits in 30 recovered OCD patients in comparison with 30 matched healthy controls. [81] They were assessed on tasks for attention, executive function, memory and intelligence. Patients had significant deficits in tests of set shifting ability, alternation, response inhibition and non verbal memory. There was no correlation between illness related variables neuropsychological deficits. The study findings suggest neuropsychological deficits are possibly state independent.
In a recent study by Viswanath et al. 25 unaffected siblings of probands with familial OCD in comparison with 25 matched healthy controls had significant deficits in tests of decision making and behavioral reversal but not in other tests of attention, executive function, intelligence and memory.[82] The deficits are consistent with the proposed neurobiological model of OCD involving the orbitofrontal cortex and suggest that the deficits could be potential endophenotypes in OCD.
Family studies
Methodologically sound studies in the last decade have reported higher morbid risk for OCD among first-degree relatives of OCD probands[83,84] but Indian studies have reported either no increase in morbid risk[85] or much less than what was previously reported.[86] The rate of OCD in 135 first- degree relatives of 33 adult OCD probands was comparable to the rate in 148 adults from the general population in the study by Guruswamy et al.[85]
In the family study of juvenile OCD, that examined first- degree relatives of 35 juvenile OCD probands and 34 matched normal controls,[86] the morbid risk for OCD among relatives of OCD probands was 5%, while none of the relatives of controls had OCD. In addition, none of the relatives had Tourette syndrome and only one relative of OCD proband had chronic tics. The study concluded that most juvenile cases of OCD were nonfamilial and unrelated to tic disorders, while only a few were familial.
Sagnik et al. examined familiality of washers and checkers by interviewing first-degree relatives of 25 checkers, 30 washers and 40 psychiatrically normal control probands. [87] The morbid risk of OCD was significantly higher among relatives of checker probands (19.4%) than in the relatives of washer (8.7%) or control probands (5.4%), while the morbid risk for relatives of washer and control probands was not significantly different. In all, 67% of the checker relatives with OCD were checkers, while 54% of the washer relatives with OCD were washers. The study provided preliminary evidence of familiality of the checker subtype of OCD.
Miscellaneous
Chakraborty et al. examined the role of oxidative stress in pathogenesis of OCD.[88] They estimated serum Thiobarbituric Acid Reacting Substances (TBARS) formed as a result of free radical lipid peroxidation in 39 newly diagnosed drug free OCD patients and 33 disease free control subjects. Patients had significantly higher TBARS than controls. In addition, there was a strong positive correlation between TBARS and the disease severity. The study suggests that oxidative stress induced increased free radical are generated in OCD patients.
OCD IN CHILDREN AND ADOLESCENTS
Demographics
In all the studies of OCD in children and adolescents reported from India, males have outnumbered female subjects.[86,89-91] Male preponderance in juvenile OCD is consistent with the previous clinical studies of juvenile OCD justifying the argument that gender distribution in OCD is developmentally sensitive.[92]
Phenomenology
A study by Khanna and Srinath from India was one of the earliest studies to systematically examine the clinical profile of OCD in children in comparison with the OCD in adults.[93] In this sample, obsessions were less frequent compared to compulsions. Obsessions of harm, religion, and impersonal images were commonly reported. Washing, praying, touching, counting and spitting were the common compulsions.
Recent studies from India[89,90] have examined the phenomenology of OCD in children using the child version of the Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), the instrument that is widely used all over the world.[94] In a study of 58 children and adolescents, all aged 16 years and below,[90] contamination obsessions were the commonest (62%), followed by obsessions related to aggression (57%), symmetry (34%), sex (22%), religion (22%), somatic (12%), and hoarding (7%). Regarding compulsions, cleaning and washing was the commonest (69%) followed by repeating (52%), checking (47%), ordering (29%), counting (15%), and hoarding (7%). The miscellaneous obsessions and compulsions were present in 65% and 47% of the subjects respectively. The phenomenology of OCD in these studies is similar to that reported in a group of 70 young patients at the National Institute of Mental Health (NIMH) in USA.[95]
In one study,[91] the phenomenology in juvenile OCD was compared with that of adult-onset OCD and juvenile-onset adult OCD, in view of the previously reported findings that juvenile OCD could be phenotypically different from adult OCD[96,97] and juvenile-onset adult OCD.[98] Obsessions related to contamination and compulsions related to checking and miscellaneous types were common in juvenile OCD. In addition, the mean Y-BOCS score was greater in the juvenile OCD and juvenile-onset adult OCD subjects compared to the adult-onset OCD subjects suggesting greater severity of OCD in the juvenile groups. The variations in the clinical manifestations support developmental variability in the expression of OCD. However, they are not consistent with specific variations reported in previous studies.[97,98] For example, OCD in juveniles was associated with a higher frequency of aggression/catastrophic obsessions, hoarding and saving compulsions.[97] Sexual obsessions were selectively more prevalent in adolescents compared with children or adults. It is possible that sexual and aggressive obsessions were underrepresented in this sample due to the fact that the subjects kept them secret because of embarrassment and possible guilt associated in revealing them. However, there could also be a true cross- cultural variation in the phenotypic manifestation of OCD.
Comorbidity
Psychiatric comorbidity is common in adults with OCD. Similarly, studies of juvenile OCD have found high rates of comorbid major depression (10%-73%), anxiety disorders (26%-76%), and tic disorders (17%-59%).[89] Three Indian studies have systematically examined the comorbidity in juveniles with OCD.[89-91] Rates of comorbid major depression, dysthymia, and bipolar disorder have ranged from 14-23%, 0-2%, and 0-2% respectively. Among anxiety disorders, rates of panic disorder, social phobia, specific phobias, overanxious disorder and separation anxiety disorder ranged from 0-6%, 0- 13%, 5-7%, 0-7%, and 5-7% respectively.
Of considerable interest is the comorbid relationship between tic disorders, disruptive behavior disorders and juvenile OCD. Rates of TS have varied from 11-15% and that of other tic disorders from 17-59%.[89] In the three Indian studies, rates of TS and chronic tics are in the range of 8-11% and 2-23% respectively. In the follow-up study by Leonard et al. TS was present in 15% of the sample and any tics in 59% of the sample.[99] The rate of TS in the Indian juvenile OCD samples is somewhat comparable to the rates in previous studies, but the overall rate of tic disorders and, in particular, chronic tics are somewhat lower. In a recent study, the clinical profile of OCD1 tics patients was examined in juvenile OCD, juvenile-onset adult OCD and adult-onset OCD subjects.[91] Miscellaneous compulsions such as touching, tapping, rubbing, blinking, staring etc (73% vs. 45% vs. 32%) and pathological doubts (40% vs. 13% vs. 9%) and ADHD (26% vs. 3% vs. 0) were over represented in the juvenile OCD group compared to the other two groups. The miscellaneous compulsions of the type reported in this study were also reported in previous studies of OCD patients with tics[100,101] but the obsessions are not similar to the ones reported in other studies that found mainly excess of aggressive, sexual, and symmetry obsessions.[101,102] Further, the elevated rate of ADHD in juvenile OCD with tics support the previous observations that ADHD, tics and OCD commonly co-occur in juvenile OCD[99,103] and are possibly interrelated sharing a common pathophysiology.[104]
Comorbid ADHD is considered by some to be a developmental marker of juvenile OCD.[105] In the study by Leonard et al.[106] the rate of ADHD was 26% and in the studies by Geller and colleagues,[97,105,107] the rate of ADHD was as high as 57%. In the three Indian studies, rates of ADHD ranged from 3 to 18%.[89-91] The rates of ADHD in Indian samples are considerably lower than the rates reported in previous studies. The samples in the previous studies by Geller and colleagues were recruited from a specialized pediatric OCD program, whereas the Indian samples were largely "self-referred" and this difference in the ascertainment method might possibly explain the variation in the rates across the samples. However, at least in one study,[91] the 18% rate of ADHD was higher than the 5-10% rate reported in community samples.[108,109] The elevated rate of ADHD in juvenile OCD in this study is consistent with the findings of previous studies[97,105,107] although the rate of ADHD is much lower than the 51-57% in children and 36-39% in adolescents reported in the studies by Geller and others.[97,107]
In the study by Jaisoorya et al. juvenile OCD was compared with adult-onset OCD, using multinomial logistic regression analysis.[91] There was positive association of chronic tics, ADHD, major depressive disorder, and Body Dysmorphic Disorder (BDD) with juvenile OCD. The TS showed an almost significant association with juvenile OCD. The BDD also had a positive association with juvenile-onset adult OCD. In addition regression analysis (juvenile-onset adult OCD vs. adult-onset OCD), showed positive association between social phobia, chronic tics and MDD and juvenile-onset adult OCD. These findings suggest that there are age-specific correlates of the disorder across the life cycle. Further, the findings suggest that OCD in juveniles is perhaps a developmental subtype of OCD with specific correlates such as high rate of ADHD and tic disorders.[96,97,107] COURSE AND OUTCOME OF JUVENILE OBSESSIVE-COMPULSIVE DISORDER
Follow-up studies of OCD in children and adolescents have reported low rates of remission.[106,110-112] Similarly, studies of adult OCD have reported worse course in those with early onset of illness.[113,114] However, studies on long-term course and outcome of OCD in juveniles are few and many have small sample sizes. We discuss here a two to nine year follow-up study of 58 children and adolescents with DSM-III-R OCD from India.[90] The subjects were largely 'self-referred' (93%) and 'drug-naïve' (90%) at the time of consultation. None had received any form of psychotherapeutic intervention and none were treatment refractory at the time of first consultation. Most were treated with medications and only a few of them with a combination of medicines and exposure and response prevention. At the time of follow-up, only 29% were still receiving medication. The median duration without any treatment at the time of follow-up was 49 months. At follow-up, 62% of the subjects were in full remission or had 'no OCD' (Total Y-BOCS score 5 0 to 3), 17% had subclinical OCD (Y-BOCS score, 4-15) and only 21% had clinical OCD (Y-BOCS . 15). The median time to achieve full remission was 24 months and subjects were symptom free for a mean of 41 months prior to follow-up assessment. However, the most significant finding is that 28 subjects (48%) were in true remission (full remission and not on any treatment) and were not receiving treatment for a mean period of 58 months. Duration of follow-up and age-at-onset emerged as significant predictors of full remission. The odds of younger subjects having full remission or no OCD outcome were 1.5 times that of older subjects. Those who had 'no OCD' at follow-up had earlier age-at- onset of illness.
The high rate of 'true remitters' is in sharp contrast to the 6% rate in the study by Leonard and others.[106] The rate of clinical OCD (21%) at follow-up is low compared to the high rates of clinical OCD (35%-68%) reported in previous studies. [106,110-112,115] Favorable prognosis in this study could be due to several reasons. First, the sample was largely 'self- referred', 'drug-naïve', moderately ill, with relatively low rate of comorbidity (55%). In the classic study by Leonard et al., the subjects were severely and chronically ill with history of treatment resistance in 75% of them and 100% comorbidity.[106] Second, a low rate of tic disorders (16%) and ADHD (3%) could have contributed to better prognosis.
The study findings suggest that juvenile OCD, at least, in self-referred, drug- naïve outpatient clinical samples has a good prognosis. The findings can be generalized to psychiatric hospital settings in India and perhaps to general psychiatric practice settings in the Western countries. Summary
Indian research on various aspects of OCD has shown broad similarities with that of research from the other parts of the world. Clinical profile of OCD seems to be similar to what is described in the literature. Comorbid patterns also appear to be similar across cultures. Follow-up studies have shown that prognosis is favorable in the long-run. There is evidence from a large Indian study that tic disorders, hypochondriasis, BDD and trichotillomania are perhaps part of the putative OC spectrum disorders. However, eating disorders are uncommon in patients with OCD.
Biological research in OCD in India has paralleled the interest in the area in other parts of the world. There seems to be a consensus that serotonergic hypothesis may not explain all the abnormalities in OCD and that complex interactions between various neurotransmitters as well as environmental factors may be necessary to cause OCD. Although not a single case of PANDAS has been reported from India, several studies have shown the possible role of immunological factors in the causation of OCD.
Substantial research has been carried out in juveniles with OCD. The rates of ADHD and TS are somewhat lower in Indian samples compared to those from other parts of the world. There is a suggestion that juvenile OCD could be a developmental subtype of the disorder. Juvenile OCD seems to have a favorable prognosis.
There is surprisingly limited amount of data from India on treatment aspects of OCD. Currently, at NIMHANS, Bangalore there is ongoing research on various aspects of OCD such as clinical profile, course, biology and treatment.
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Y. C. Janardhan Reddy Naren P. Rao Sumant Khanna Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS) Hosur Road, Bangalore - 560 029 Karnataka, India Trivedi & Gupta: Research in anxiety disorders 32 An overview of Indian research in anxiety disorders
J. K. Trivedi, Pawan Kumar Gupta
ABSTRACT
Anxiety is arguably an emotion that predates the evolution of man. Its ubiquity in humans, and its presence in a range of anxiety disorders, makes it an important clinical focus. Developments in nosology, epidemiology and psychobiology have led to significant advancement in our understanding of the anxiety disorders in recent years. Advances in pharmacotherapy and psychotherapy of these disorders have brought realistic hope for relief of symptoms and improvement in functioning to patients.
Neurotic disorders are basically related to stress, reaction to stress (usually maladaptive) and individual proneness to anxiety. Interestingly, both stress and coping have a close association with socio-cultural factors. Culture can effect symptom presentation, explanation of the illness and help-seeking. Importance given to the symptoms and meaning assigned by the physician according to their cultural background also differs across culture. In this way culture can effect epidemiology, phenomenology as well as treatment outcome of psychiatric illness especially anxiety disorders. In this review an attempt has been made to discuss such differences, as well as to reflect the important areas in which Indian studies are lacking. An attempt has been made to include most Indian studies, especially those published in Indian Journal of Psychiatry.
Key words: Anxiety disorder, Indian studies and review, neurotic disorders
INTRODUCTION
Anxiety is arguably an emotion that predates the evolution of man. Its ubiquity in humans, and its presence in a range of anxiety disorders, makes it an important clinical focus. Developments in nosology, epidemiology and psychobiology have significantly advanced our understanding of the anxiety disorders in recent years. Advances in pharmacotherapy and psychotherapy of these disorders have brought realistic hope for relief of symptoms and improvement in functioning to patients.
ANXIETY DISORDERS
The word anxiety is derived from the Latin "anxietas" (to choke, throttle, trouble, and upset) and encompasses behavioral, affective and cognitive responses to the perception of danger. Anxiety is a normal human emotion. In moderation, anxiety stimulates an anticipatory and adaptive response to challenging or stressful events. In excess, anxiety destabilizes the individual and dysfunctional state results. Anxiety is considered excessive or pathological when it arises in the absence of challenge or stress, when it is out of proportion to the challenge or stress in duration or severity, when it results in significant distress, and when it results in psychological, social, occupational, biological, and other impairment.
CLASSIFICATION OF ANXIETY DISORDERS
The DSM-IV (American Psychiatric Association)[1] includes the following major categories of anxiety disorders: Panic disorder (with or without agoraphobia), agoraphobia without panic, social phobia (social anxiety disorder), specific phobia, generalized anxiety disorder (GAD), acute stress disorder, posttraumatic stress disorder, obsessive compulsive disorder, and anxiety disorder not otherwise specified. DSM-IV also lists anxiety occurring as an adjustment disorder, or secondary to substance abuse or a general medical condition. Finally, anxiety not amounting to a psychiatric diagnosis could be situational in normal persons, or a symptom of another psychiatric disorder.
WHY THIS REVIEW OF ANXIETY DISORDER RESEARCH IN INDIA
Neurotic disorders are basically related to stress, reaction to stress (usually maladaptive) and individual proneness to anxiety. Interestingly, both stress and coping have close association with socio-cultural factors. Culture can affect symptom presentation, explanation of the illness and help-seeking. Importance given to the symptoms and meaning assigned by the physician according to their cultural background also differ across culture. In this way culture can affect epidemiology, phenomenology as well as treatment outcome of psychiatric illness especially anxiety disorders. In this review an attempt has been made to highlight on any such difference if there, as well as this review will also reflect the important areas, in which Indian studies are lacking.
This review will summarize most Indian studies pertaining to anxiety disorders published in Indian Journal of Psychiatry as well as found in other journals too.
EPIDEMIOLOGICAL STUDIES
To the author's knowledge there are three meta-analyses of Indian epidemiological studies of psychiatric disorders. A meta-analysis of 13 psychiatric epidemiological studies (Reddy and Chandrashekhara)[2] with a total sample size of 33,572 subjects who met the following criteria; door- to- door survey, all age groups included and prevalence rate for urban and rural being available, yielded an estimated prevalence rate of 20.7% (18.7-22.7) for all neurotic disorders, which was reported to be highest among all psychiatric disorders. The weighted prevalence rates of different anxiety disorders were 4.2% (Phobia), 5.8% (GAD), 3.1% (Obsession) and 4.5% (Hysteria). Panic disorder was not included in this meta-analysis and the reason for this is surprisingly not discussed. This meta-analysis also reported that prevalence rates of all neurotic disorders except hysteria (5.0% vs. 3.4%, P , 0.5) were significantly higher (35.7% vs. 13.9%, P , 0.01) in urban communities than rural, and all neurotic disorders were significantly high among females (32.2% vs. 9.7%, P , 0.01). Though meta-analysis has its own limitations, this was the first attempt to analyze the epidemiological studies.
It has been seen that rural epidemiological studies are more difficult to conduct as compared to urban ones, due to ignorance, stigma and lack of resources. Disorders like obsessive compulsive disorder often go unaccounted due to ignorance and attribution of such issues to personality factors.[3] This can be a possible explanation for higher prevalence of anxiety disorders in urban areas than to the same in rural areas. Disorders like hysteria are accounted in a more reliable manner and are significantly more common in rural communities because of visible manifestation of the disease (Reddy and Chandrashekhara).[2]
Ganguli[4] analyzed 15 epidemiological studies on psychiatric morbidity in India. In this meta-analysis prevalence rate (in per thousands) of anxiety neurosis was reported to be 16.5 with a rural urban ratio of 100:106 and that of hysteria was 3.3 with a rural urban ratio of 100:44. These findings of meta- analysis were consistent with that of reported in meta-analysis by Reddy and Chandrashekhara.[2] Except hysteria, the prevalence rates of various anxiety disorders included in the anxiety neurosis were not separately assessed, thus leaving us blindfold in the overall affliction of the population from these individual disorders. Madhav,[5] in an analysis of 10 Indian studies on psychiatric morbidity, concluded that prevalence rates for anxiety neurosis and hysteria were 18.5 and 4.1 per 1000 population respectively. The common feature of the two meta-analyses described above was that they included studies which were conducted in three steps or phases;
1. Delineation of the sample and initial contact with subjects including collection of background demographic data.
2. Identification of suspected cases, usually on the basis of interviews and questionnaire by non-psychiatric personnel like social workers and sometimes by psychological tests. Physical examination of suspected cases by medical personnel was part of this phase.
3. Psychiatric examination and clinical diagnosis and classification of suspected cases were the third stage.
Epidemiology of anxiety disorders in elderly
Epidemiological data of anxiety disorder in special population like pediatric and elderly are scant. To the best of the author's knowledge, one population- based study on geriatric population was reported by Tiwari and Srivastava.[6] These authors identified 488 elderly subjects in a rural region of Uttar Pradesh. Nearly 9% of the subjects were diagnosed with ICD-9 (World Health Organization) [7] anxiety neurosis. These data may contain unknown biases because over 42% of the geriatric population was assigned a psychiatric diagnosis; in contrast, less than 4% of non-geriatric subjects had an ICD-9 psychiatric diagnosis.
Epidemiology of anxiety disorders in pediatric population
A prevalence rate of psychiatric morbidity among pediatric population has been reported since very early (Sethi et al.) [8,9] but these studies did not report prevalence rates of anxiety disorders separately. In one of the earliest known report on neurotic disorders, Nagaraja[10] observed childhood neuroses in 9.7% of out-patient population and 9.3% of inpatients over a period of seven years in Hyderabad with a male to female ratio of 1:2. Manchanda et al.[11] found neurotic behavior in 27.3% children admitted for physical ailments. In children seen at the Child Guidance Clinic of the Madras Government General Hospital during the year 1964-1966, Raju et al.[12] found that 22 of the 592 children were neurotics and 16 were hysterical. Later, in an urban survey of 109 families for psychiatric morbidity in children below 12 years, Lal and Sethi[13] reported emotional disturbance in 55% families and 35.4% of the total children surveyed. Neurotic disorders were found in 11.0% of the total sample, but the clinical states mentioned therein were extremely varied and did not follow any classificatory scheme.
In an another epidemiological study conducted by Manchanda and Manchanda,[14] a total of 19 children (up to 12 years) from the Pediatric inpatient and Child Guidance Clinic (CGC) were diagnosed to be suffering from a neurotic disorder during a period of 11 months. Incidence of neuroses was 1.1% among pediatric inpatients and 8.2% in CGC. The incidence was higher in the females. 73.5% of children were in the age range of 10-12 years. None of them were below six years. Hysteria was the commonest diagnostic group (71.4%) in the present study. Therefore, it is likely that the findings observed for neurotic disorders in general, are more characteristic of hysteria. Other disorders in order of frequency were anxiety (16.3%) depression (6.1%) and phobia (4.1%). Obsessive compulsive neurosis was observed in one case only.
In another epidemiological study of possession syndrome (Venkataramaiah et al.)[15] conducted in West Karnataka reported high prevalence rates of 51% in age group ,15 years and 28% in age group 15-25 years (n 5 718). In this study a house to house survey was conducted for a population of 1158 in west Karnataka to determine the prevalence of possession syndrome and to study people's attitude towards the same. One year period prevalence was found to be 3.7%.
Recently a community-based study was conducted by ICMR in Lucknow (ICMR,)[16] and Bangalore (Srinath et al.)[17] in children and adolescent age 0- 6 years. The prevalence rates of various anxiety disorders, reported in the study are shown in the Table 1.
CONCLUSION
Most of the epidemiological studies done in India neglected anxiety disorders. The use of poor sensitive screening instruments, single informant and systematic under- reporting has added to the discrepancy in the prevalence rate. The prevalence of mental disorders reported in epidemiological surveys can be considered lower estimates rather than accurate reflections of the true prevalence in the population (Math et al.).[3]
Most of the Indian epidemiological studies analyzed here have surveyed a population less than 6000. This raises a query whether the findings can be generalized to even one State of India. Mental health care priorities need to be shifted from psychotic disorders to common mental disorders like depression, anxiety disorders, somatoform disorder, etc., which are also associated with high disability in all measures (Patel et al.).[18]
STUDIES RELATED TO PHENOMENOLOGY, CO- MORBIDITY AND OTHER CLINICAL VARIABLES
Studies on hysteria, conversion or dissociative disorders [Table 2]
In children and adolescents, review of literature shows that common disorders seen are dissociative convulsions and stupor.[26-29] Symptoms of motor weakness, amnesia, and aphonia are less commonly seen. The common stressors reported were academic difficulties, family problems, peer problems, sibling rivalry and at times difficult situations like marriage etc.[30,26,31] Common co-morbidities reported were depressive disorder, anxiety disorders, adjustment disorders, oppositional defiant disorder and specific developmental disorder of scholastic skills.[28] Differential diagnoses could be epilepsy, involuntary movement disorders like chorea, dystonias, syncopal attacks, panic attacks and other neurological disorders. Good outcome of dissociative disorders have been reported.[26,28,29] Early diagnosis, presence of a psychosocial stressor and appropriate intervention has been associated with good out come in these patients.
Panic disorders
The phenomenology of panic disorder has been studied widely in the West but rarely in India. Srinivasan and Neerakal[32] studied 94 panic patients attending the OPD of psychiatry department. This study has shown considerable co-morbidity of major depression (according to DSM-IV criteria) in 43 patients (45.7%) with panic attacks. Majority (i.e. 69.8%) of the subjects with panic attacks had co-morbid primary depression and only 30.2% had secondary depression. More so, there was a greater prevalence of concurrent generalized anxiety disorder in panic patients with depression (both primary and secondary) as compared to panic patients without depression. Authors of this study have mentioned that their findings are in alignment with those of Western studies. Cross-sectional design of this study was its major limitation.
A longitudinal study would have been more clearly identified the relationship between panic disorder and depression.
Social anxiety disorders
Social Anxiety Disorder (SAD) is a chronic, disabling and treatable disorder with common onset in adolescence. There is only one study conducted by Mehtalia and Vanker[33] to find out frequency, demographic and phenomenological characteristics of SAD, family related risk factors, academic impairment and co morbidity of depression among adolescents. A total of 421 adolescents in one high-school were screened for SAD and depression and associated factors with academic impairment. 54 (12.8%) had SAD. The most common manifestation of SAD was avoiding giving speeches. SAD was equally common among both genders, was associated with difficulty in coping with studies, concern about weight, having less friends, lack of intimacy with parents, and being treated differently from siblings. This study concluded that SAD is a common adolescent disorder, with major depression as co-morbidity and associated with impairment in academic functioning. All adolescents, especially with depression consulting medical professionals, should be interviewed for SAD and treated. The findings of this study are based on only one stage screening. The findings need to be replicated in further two-stage study employing structured clinical interview for more valid conclusions. Although this study has explored the most common co- morbidity i.e. major depression, other anxiety disorders and relationship with avoidant personality disorder has not been explored. Future studies on this aspect are also needed.
Post traumatic stress disorders
PTSD has a global significance, and its impact in countries that have been experiencing repeated disaster and social unrest for many years could be a large public health problem. Despite having a global significance, its prevalence has been best studied in industrialized societies only particularly in USA.[34] It is unclear whether US data can be generalized to other developed countries.[35] The situation is almost certainly quite different in the developing countries where large proportion of population have been exposed either directly or indirectly to terror attacks, torture, sexual assault, and forced relocation.[36-38] Estimates of the prevalence of PTSD in the general population of the countries other than America are lacking.[39] There are no published or detailed studies available so far from India except a few national and international conference presentations.[40-48] Published data in this area is dismally minimal and there is need for further research. Following are the studies related to PTSD, which have been published in recent years [Table 3]. Obsessive-compulsive disorders
The very first paper published in Indian Journal of Psychiatry, in 1951, was authored by Dr. P.K. Ray, titled "Common Obsession –compulsive symptoms in India". [52] In this paper an attempt was made to relate abnormal mental phenomenon in India to the cultural and religious background of Hinduism as found in Bengal. But there was no attempt made at psychological and psycho- analytic interpretation of these symptoms. Since then there are a few studies related to phenomenology and various clinical variables have been published from India.
Akthar et al.[53,54] tried to delineate obsessions and compulsions based on form and content from a phenomenological view. They identified five types of obsessions: Doubts, obsessive thinking, fear, impulses and images. In compulsions, they identified two types, yielding and controlling compulsions. They identified six varieties of thought content: Dirt and contamination, aggression, inanimate-impersonal, sex, religion and miscellaneous. They opined that form is affected by intrinsic factors and content by extrinsic factors.
Khanna et al.[55] tried to establish a phenomenological system of classification for various phenomena observed in OCD, using a classificatory system for obsessions (Khanna and Channabasavanna),[56] and compulsions (Khanna and Channabasavanna),[57] which had high inter-rater reliability (Khanna et al.),[58] They derived 6 forms and 10 contents of obsessions and four forms and six contents of compulsions. These variables were used for cluster analysis. Seven clusters emerged, of which four were considered important. (1) Checking, (2) Washing, (3) Past, (4) Embarrassing behavior. Though washing and checking constituted two largest pure clusters, there was significant overlap, which is due to their frequent co-occurrence. These studies had their own methodological limitations. There are two more recent studies regarding the phenomenology and course of OCD, published in the IJP which has been tabulated below [Table 4].
BIOCHEMICAL STUDIES
Understanding the biology of various psychiatric disorders has taken the front seat in psychiatric research. Indian studies particularly on this area of anxiety disorders are very less [Table 5].
STUDIES ON COGNITION IN ANXIETY DISORDERS
Only a few studies have assessed neuro-cognitive domains in anxiety disorders. A study by Tarafder et al.[65] on 20 patients of OCD found impairment of executive functions when assessed on WCST. Another study by Trivedi et al.[66] on 30 patients of OCD found that the patients of OCD performed significantly worse on cognitive measures (evaluated on WCST, CPT and SWMT) than healthy controls.
STUDIES ON LIFE EVENTS AFFECTING ANXIETY DISORDERS
Bhatti and Channabasavanna[67] studied neurosis through stressful life events, personality dimensions, family interactional patterns and other sociological variables. They studied 60 neurotics and 60 controls, 92% respondents had stress in more than one area like work, education, family etc in the experimental group. The mean number of stressful life events experienced by neurotics over a period of one year was around 5, which is much higher than the normal population. Only 40% respondents in the control group had stress in just one area.
Sharma and Ram[68] carried out a study on 84 patients of anxiety neurosis and 47 controls. On assessing the life events during life time and six months prior to the onset of illness by an open ended interview, using a scale suited for Indian population, frequency and stress scores experienced by patients and by controls was observed. It was observed that a variety of events were significantly more frequent in the patient group. Events related to personal, social, sexual, educational, occupational and financial areas were observed significantly more in patients during life time and six months prior to the onset of illness. Four events, namely, suspension from job, theft or robbery, broken engagement or love affair and conflict over dowry were found to be
significantly more in patients during lifetime. Four other life events such as major purchase or construction of house, failure in exam, appearing for interview and getting engaged or married were found to be significantly more in patients during the six months prior to the onset of the illness. Thus patients experience a variety of life events often more often than the controls.
STUDIES BASED ON TREATMENT AND MANAGEMENT OF ANXIETY DISORDERS
Studies based on treatment of anxiety states or disorders are being published in Indian Journal of Psychiatry since 1959. The initial few published studies have been - Effect on anxiety states of carbon dioxide Jetley,[69] and Guaiacol glycerol ether (Mehta et al.),[70] Trial of haloperidol in anxiety states (Jairam and Ram),[71] double blind placebo-controlled trial of Trioxazine (Katira and Iyer),[72] clinical trial of Pimozid in anxiety (Ramchandran and Menon),[73] and study of prochlorperazine in anxiety disorders (Nigam et al.)[74]
The first Indian study on the effect of Benzodiazepines in anxiety disorders was conducted by Master and Kajaria.[75] This double-blind study was done on 60 outpatients to compare the efficacy of Lorazepam and Diazepam in anxiety neurosis. It concluded that both Lorazepam and Diazepam are effective anxiolytics but a clinically satisfactory response occurs earlier with Lorazepam. Effect of Clobazam, a nonbenzodiazepine anxiolytic was studied by Singh et al.[76] and later compared with the Diazepam (Channabasavanna and Pereira).[77]
Khanna et al.[78] studied 12 subjects with a diagnosis of OCD who had not shown response to Amitryptiline and Imipramine/behavior therapy those subjects underwent a cross over double blind trial with Clomipramine and Nortryptiline. Subjects who had earlier not shown response to the other drugs did not show response to Clomipramine. This study provides tentative evidence that an adequate trial of Imipramine and Amitryptiline should be given in all cases of OCD, and that if subjects do not respond to these two drugs, it is unlikely that they will show response to Clomipramine.
Shah et al.[79] conducted a controlled double blind trial of Buspirone and Diazepam in generalized anxiety disorder. Patients in both groups showed improvement on Hamilton Anxiety Scale. However, in the Buspirone group, improvement was seen in cardiovascular, somatic autonomic, anxious and mood symptoms; while in the diazepam group, improvement was noticeable in anxious mood, tension, insomnia, cognitive symptoms, somatic and cardiovascular symptoms. The mean total daily dosage required by the patient in the Buspirone group was 36.56 mg/ day, which was more than reported elsewhere.[80,81] More patients in the Buspirone group dropped out midway in the trial compared to Diazepam group. The lag time of anxiolytic efficacy of Buspirone is longer and thus motivation for compliance is necessary.
Shah et al.[82] evaluated Alprazolam and Diazepam in GAD, diagnosed by DSM III criteria in a double blind multicentric study. Weekly evaluations were systematically carried out for a period of four weeks; 148 patients (79%) completed the trial. Results showed that Alprazolam was as effective as diazepam as an anxiolytic. Drowsiness was less often reported with Alprazolam. This was the short follow-up study; the efficacy of Alprazolam in long term use needs to be evaluated.
Sahasi et al.[83] ascertained the effectiveness of different relaxation techniques in the management of anxiety. Earlier study by Sahasi et al.,[84] found significant improvement among patients undergoing yoga therapy compared to those taking minor tranquilizer (Diazepam). In the 1991 study, psychological and self report data were obtained from the participants practicing progressive relaxation and yogic techniques of relaxation. Both techniques generated positive expectancies and produced a decrease in a variety of self-reported symptoms. Yogic techniques produced greater motivation to practice than progressive relaxation. The follow-up rate was much better among the yoga group than those who were doing progressive relaxation. Yogic techniques are more readily acceptable by our population. Following the yogic way of life probably acts as a psycho prophylactic against anxiety.
Vahia et al.[85] conducted a study to compare the efficacy of meditation with that of Imipramine and Chlordiazepoxide in the treatment of GAD, diagnosed as per DSM III criteria. At the end of five weeks, meditation was found to be as effective as pharmacotherapy in controlling symptoms of anxiety. It was superior in altering trait anxiety. Meditation is an easy to learn and effective therapy. It has a distinct advantage over pharmacotherapy in that it does not have the associated problems of habit formation, withdrawal effects, over dosage or other undesirable effects.
Andrade et al.[86] conducted a double-blind controlled evaluation of the efficacy and adverse effect profile of sustained release Alprazolam. Disadvantage of Alprazolam is that its anxiolytic efficacy wears off much earlier than the drop in its blood levels. Therefore, thrice or even 4 times daily dosing may be necessary, despite which inter-dose anxiety is some times a clinical problem. In patients with panic disorder, sustained release Alprazolam was found to be as effective as conventional Alprazolam, the SR formation was also well tolerated (Schweizer et al.).[87] India is probably the only country in which a sustained release preparation of Alprazolam is commercially available. 40 patients with GAD, as per DSMIV diagnosis and stabilized on Alprazolam therapy were randomized to receive first the same dose of either conventional or sustained release Alprazolam for two weeks, followed by the other formulation of Alprazolam in an identical dose for a further two weeks. No efficacy difference was observed between the two forms of Alprazolam. Once-daily SR formulation is as effective as the conventional form of the drug. It's use in drug naive patients and examining the long-term efficacy, compliance and withdrawal in naturalistic studies would be essential.
CONCLUSION
Status of anxiety disorder research from India in relation to epidemiology, phenomenology, course, outcome and management are lacking. Research areas like family studies, genetics, and neurobiology are not touched adequately. Most of the studies have tried to replicate the findings from the West. Despite rapid advancement in the field of psychopharmacology, the researches in the field of anti-anxiety and antidepressant drugs are dismally low from India. Furthermore research is lacking in the areas of non- pharmacological management like relaxation therapies, yoga, other meditation techniques and psychotherapies despite India being the birth place of many such techniques. Most of the research is done by tertiary centers involving limited sample which may not provide the real picture.
ACKNOWLEDGEMENT
The authors would like to thank Dr. Himanshu Sareen, M.D., Senior Resident for all his help.
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Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiat. 1972: 26: 57. 65. Tarafder S, Bhattacharya P, Paul D, Bandyopadhyay G, Mukhopadhyay P. Neuropsychological disposition and its impact on the executive functions and cognitive style in patients with obsessive-compulsive disorder. Indian J Psychiatry 2006;48:102-6. 66. Trivedi JK, Trivedi JK, Dhyani M, Goel D, Sharma S, Singh AP, Sinha PK, et al. Neurocognitive dysfunction in patients with obsessive compulsive disorder. Trivedi. Afr J Psychiatry 2008;11:204-9. 67. Bhatti RS, Channabasavanan SM. Study of neurosis: Life event, and personality dimensions. IJP 1985;27:127-37. 68. Sharma I, Ram D. Life events in anxiety neurosis, UP. Indian J Psychiatry 1988;30:61-8. 69. Jetley SK. Corbon di-oxide therapy in neuroses. Indian J Psychiatry 1959;1:61-3. 70. Mehta CH, Vahia NS, Bagadia VN, Desai A. Guaiacol glycerol ether (GGE) in anxiety states. Indian J Psychiatry 1960;2:16-20. 71. Jayaram SS, Ram PK. Methods of assesment in a trial of haloperidol in anxiety neurosis. Indian J Psychiatry 1971;13:131-5. 72. Katira MN, Iyer DS. A double blind trial of trioxazine with placebo in anxiety states. Indian J Psychiatry 1972;14:287-8. 73. Ramachandran V, Menon MS. A clinical trial of pimozide in anxiety state. Indian J Psychiat 1977;19:79-82. 74. Nigam P, Rastogi CK, Kapoor KK, Gupta AK. Prochlorperazine in anxiety. Indian J Psychiatry 1985;27:227-32. 75. Master RS, Kajaria SM. A controlled evaluation of 'lorazepam' and diazepam in anxiety neurosis. Indian J Psychiatry 1974;16:42-7. 76. Singh G, Kumar V, Kapur R. Control clinicial trial of a new anxiolytic 'clobazam'. Indian J Psychiatry 1984;26:141-6. 77. Channabasavanna SM, Pereira LM. Clobazam single or divided dose against diazepam in anxiety neuroses. Indian J Psychiatry 1986;28:51-4. 78. Khanna S, Rajendra PN, Channabasavanna SM. Clomipramine in resistant obsessive compulsive disorder. Indian J Psychiatry 1988;30(4), pp. 375-379 79. Shah LP, Mazumdar K, Prakar RS, Ghodke RR, Mangakias D, Shah AN. A controlled double blind clinical trial of buspirone and diazepam in generalized anxiety disorder. IJP, 1990; 32:166-9. 80. Goldberg, Finnerty (1982) Comparison of buspirone in two separate studies. Journal of Clinical Psychiatry, 43(2),87-91. 81. Pecknold, Familamiri, Chang, Wilson and Alarcia (1985) Buspirone: Anxiolytic? Progress in Neuro-Psychopharmacology. Biological psychiatry, 9,639-42. 82. Shah LP, Parikh R, Elavia E, Murthy RS, Chatterjee S, Sriram TG, et al. Comparative evaluation of Alprazolam and Diazepam in treatment of anxiety: A double blind multicentric study. IJP, 1991;33:126-30. 83. Sahasi G, Chawala HM, Dhar NK, Katiyar M. Comparative study of progressive relaxation and yogic techniques of relaxation in management of anxiety Neurosis, IJP 1991;33:27-32. 84. Sahasi G. Mohan V. and Kacker C. Effectiveness of Yogic techniques in the Management of Anxiety. Journal of Personality and Clinical Studies1989; 5:1:51-55. 85. Vahia VN, Shetty HK, Motiwala S, Thakkar G, Fernandes L, Sharma CJ. Effect of meditation in generalised anxiety disorder. IJP 1993;35:87-92. 86. Andrade C, Aswath A, Chaturvedi SK, Raguram R, Bhide A. A double blind controlled evaluation of the efficacy and adverse effect profile of sustained release alprazolam. Indian J Psychiatry 2000;42:302-7. 87. Schweizer E, Patterson W, Rickels K, Rosenthal M. (1993) Double-blind, placebo- controlled study of a once-a-day, sustained-release preparation of alprazolam for the treatment of panic disorder. American Journal of Psychiatry, 150, 1210-1215.
J. K. Trivedi Pawan Kumar Gupta Department of Psychiatry, C.S.M. Medical University, U.P. (erstwhile K.G. Medical University), Lucknow - 226 003, India Shastri et al.: Child and adolescent psychiatry 33 Research in child and adolescent psychiatry in India
Priyavadan Chandrakant Shastri, Jay P. Shastri, Dimple Shastri
ABSTRACT
The primary source for this annotation on child and adolescent psychiatry is Indian Journal of Psychiatry. Articles covering various dimensions of child and adolescent mental health were searched from its electronic data base to discuss relevant articles. Literature was mainly in the form of original research articles, review articles, case reports, editorials, orations and presidential address.
Key words: Child, adolescent, mental health, mental illness, original articles, review articles, case reports
INTRODUCTION
In India, child mental health services have been neglected in the last 63 years. National Mental Health policy makers (2003) have practically nothing on their agenda as far as child mental health policy and planning are concerned. It is a sorry state of affairs. In last 67 years, from 1937 when first child guidance clinic was introduced till 2003, NIPCCD study located only 164 Child Guidance Cinics (CGC); roughly two CGC a year and that too only in metro cities and mega cities. All these child guidance movements and mental health activities, services have been initiated and sustained by efforts from non-governmental organizations (NGOs).[1]
Ten per cent of the child population is in need of special care and treatment. Only one out of the 100 gets some care and treatment. It is high time we reach out to 99% of the child population that is being unattended by any agency. Children with borderline intellectual functioning and various learning, speech, visual and hearing difficulties are conservatively estimated to be 20% of the total child population. These 114 million children have no facilities even in the urban areas.[1] Child population is not homogeneous. Large numbers of children have no home, school and family. They can be in orphanages, destitute homes, beggars' homes, juvenile homes, rescue homes and remand homes. They can even be street children. All these groups some how have their own self-help group, one of the motto of such group is "each one teach one" to become self- sufficient. Some of them run their own child guidance clinic.[1]
Child psychiatry in the West expanded rapidly in the 60s and 70s. Strikingly, Indian Child Psychiatry has been part of general psychiatrist and that trend has grown much more in last two decades. Mumbai, Bangalore and Lucknow had considerable child mental health activity. General psychiatrist offered their services to children in many diverse ways. They are to be found working in many fields child's home, remand home rescue home, delinquency, cerebral palsy and other handicap.[2]
Multidisciplinary child practice
Child mental health is not in the province of child psychiatry alone. Education, social welfare, primary health services, even community leaders and neighbors contribute more than child psychiatry on its own. The team work always does wonders in child psychiatry. Important key members of the team include psychiatrist, psychologist, social worker, neurologist, pediatrician, occupational therapist, speech therapist, physiotherapist, special educator, art, music, drama therapist and cytogenetic expert.[2]
Cooperation with the educational services
School Mental Health has been a major mental health movement which covers up the large population of children and adolescent, but has been effectively implemented only in metros and not in smaller towns and urban areas in the last four decades. Research publications during the 60s, 70s and 80s reported that mental retardation formed bulk of population attending CGC during that period. While emotional and behavioral disturbances were less identified and referred. The trend has changed. All spectrums of diagnostic categories are now referred and treated at various teaching hospitals, psychiatry departments, pediatric departments, various colleges of social work and large number run by NGOs.[3]
The last three decades has shown highly specialized clinics rendering specialized services to children with learning disability, autism, cerebral palsy and mental retardation mostly in metros and urban areas. Such centers do run the genetic clinic and research in specific disorders. Development clinics for 0 to 3 years age group for various disability groups and multiple disability groups have special focus of identification, assessment and therapy. All these centers are attended by general psychiatrist rendering highly specialized services.[3]
Child Mental Health Policy and School Mental Health programs have provided excellent opportunity to enhance mental health program for children and adolescents. The focus is rightly on preschool children and school based mental health program, which will prevent illness and possibly promote positive mental health. It also ensures that it will reduce behavior disorders in children and prevent adult psychopathology. Effectiveness of child mental health intervention programs will surely help in addressing mental health disorders among adults.[4]
In order to achieve desired outcomes one should embrace all those services that contribute to the mental health care of children and adolescents, whether provided by health, education, social services or other agencies. It is also crucial to partner with services whose primary function is not mental health care, such as GPs and schools. They can always contribute by offering general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development and refer to more specialist services. This is to explicitly acknowledge that supporting children and adolescent with mental health problems is not the responsibility of specialist services alone.[4] Importance of need for school- based programs has been reflected in inclusion of life skill education program by NCERT and CBSC in present syllabus.
According to the UNESCO report 2008. (U.N.D.P. Report 2008) India stands at
• 102nd position in the "Education for all developmental index" out of 129 countries
• 132nd place in the list of 172 nations on human development index (HDI)
Ten per cent of 5-15 year old has a diagnosable mental health disorder. This suggests that around 50 million children under 18 would benefit from specialist services. There are up to 20 million adolescents with severe mental health disorders. Around 90% children with a mental health disorder are not currently receiving any specialist service.[4]
REVIEW OF LITERATURE
Attention deficit hyperactivity disorder
Prevalence of hyperactive syndrome in 2160 primary school children between 6-12 years was found to be 4.67%. Ratio of male to female distribution was 4.74:1. Sleep related problems may have significant bearing on the course and management of ADHD. At least one sleep related problem was present in 65.62% of children in ADHD group and 30% in the sibling group. A careful evaluation of sleep history is recommended in children with ADHD. ADHD is observed as a comorbid psychopathology in large number of disorders like substance abuse, mental retardation, autism, conduct disorder, cerebral palsy, learning disorders and medical illnesses.[5,6]
Child and family
A child is born and brought up in a family. Family dynamics plays a vital role in mental health and illness. Psychologically and physically broken home has been reported in both the depressive and schizophrenic psychopathology. Child rearing practices can retard or accelerate development of child health. Schizophrenogenic parents and refrigerator parents who are cold and apathetic, produce autistic and psychotic child behavior.[7-10]
Co morbid disorders
Prevalence of behavioral disturbance in children with nephrotic syndrome was 68%, significantly higher than that in the control group 21.6%. The behavior abnormalities found in the nephritic syndrome group were hyperkinesis, obsessive compulsive neurosis, conduct disorder, and emotional disorder in that order. Frequency of relapse and low socio- economic status showed significant association with presence of behavior disorder in the nephritic syndrome group. This association persisted even after adjusting for other socio-demographic, disease, treatment related variables including steroid therapy.[11]
Delinquency, conduct problems and criminality
The evidence is clear that prevention and intervention must begin early, preferably during preschool years. Early intervention is especially critical for children growing up. Research strongly indicates that interventions becomes more difficult and encounters more intransigent behavior pattern from teenagers who exhibit antisocial behavior from an early age. Life course persistent offender who enters adolescence fully engaged in delinquent or antisocial behavior is usually highly resistant to change.[12]
The prevalence of the conduct disorder was 4.58% more common in boys, majority had childhood onset and one-third had comorbid ADHD. A study of Esser and colleagues reported prevalence of 0.9%, while Kashani et al. reported prevalence of 8.7%; DSM IV reports prevalence in males 6-10% and females 2-9%. The ratio of male to female CD is lower for the adolescent onset type than for the childhood onset type. Among the Indian studies Deivasigamani has reported the prevalence of CD to be 11.13%, Sarkar et al. reported prevalence rate of antisocial behavior to be 7.1% while recently Srinath et al. have reported prevalence as low as 0.2%. Attention-deficit hyperactivity disorder (ADHD) is the common co morbidity in children with conduct disorder.[13]
Epidemiology
Various studies have shown a higher prevalence of different specific developmental disorders in males, being two to four times more common in boys than girls. Malhotra et al. while studying the incidence of childhood psychiatric disorders in the community found its rate to be 18/1000 years; the rate could be said to range between18-37/1000 years. The highlighted the need for such large scale studies to understand the rates and pattern of causation.[14,15]
Mental retardation
Considerable focus has been on study of various facets of mental retardation. The area that has been discussed widely include types of retardation, assessment, prevalence, causes, genetic and biochemical screening, study of behavioral patterns, comorbidity personality pattern of parents and their attitude along with socio-economic studies. Fewer studies have focused on multidisciplinary management and long term care in institution for children with mental retardation.[16-20]
Neurosis
Neurotic disorders constitute one of the common psychiatric problems met with in children. Among the neurotic disorders majority of the cases reported were hysteria (40-70%). Children tend to pick up considerable symptom pathology from parents or within the family.[21-24]
Psychopharmacology
Psychiatric illnesses are common during pregnancy and post-partum period. Treatment of this condition is important as they can affect the health of the mother and fetus/infant. Issues become even more complex with multiple drugs and if there are associated medical problems or the infant is premature. Important issues to be kept in mind include folate supplementation in all women in the reproductive age group; planning pregnancies to minimize fetal exposure, discussion with the patient and family regarding options and documentation of all discussions and decisions. Active liaison with obstetricians, ultrasonologist and pediatricians need to be stressed, as also the need for local registries. Whenever possible use non-pharmacological approaches in addition. If psychotropic is necessary the choice of medication should be guided primarily by its safety data during pregnancy and breast feeding and by the psychiatric history of the patient.[25]
Children are not miniature adults. Psychopharmacokinetics and dynamics needs to be understood before administration of any molecule. One needs to know longitudinal safety data on child development and growth.
Schizophrenia
Schizophrenia has been considered to be a neurodevelopmental disorder and the Childhood Onset Schizophrenia (COS) offers an important opportunity to examine abnormal neurodevelopment in this disorder. SPECT and neuropsychological findings in COS converge with those of Adult Onset Schizophrenia (AOS) but with greater temporal lobe involvement in COS. This is the first SPECT study in COS; therefore, the findings could be compared only with MRI studies that are available and depicts structural abnormalities. There is complex interaction between structural and functional systems in the CNS. As SPECT studies advance it may be possible to physiologically characterize, classify and diagnose various neurobiological and psychiatric disorders and possibly predict therapeutic effect and outcome.[26]
Substance abuse
Rajkumar Bansal's study highlights substance use pattern of 300 child laborers from six slums in Surat city and identifies the microsocial and macro- social stressors which initiates and perpetuates their substance use. It was observed that 135 (45%) of the child laborers had used some substance with mean 1.5 substances used per child. Tobacco smoking was the most common form of substance abuse, followed by tobacco chewing, snuff, cannabis and opium. This study highlights an urgent need for the containment of substance abuse by these vulnerable early initiators. The 'maturation hypothesis' that young people grow out of their drug related problems as they grow older need to be revised. India has 15-45 million child laborers at risk who are subject to rampant and unabated exploitation.[27-30]
Significantly higher number of early onset alcohol dependence subjects had history of ADHD and/or ADD, RT compared to the late onset. There is need for greater evaluation of ADHD in populations of adults with alcohol dependence, especially those with early onset, and more intensive management of this high risk group in view of their poorer prognosis. Since treatment of ADHD in adolescent including stimulants is known to reduce substance use, including alcohol use, assessment of comorbid ADD, RT in adults has important therapeutic implications.[31]
Suicide
Sharma et al. reported about 15.8% adolescents in South Delhi thought of attempting suicide while 5.1% actually attempted suicide. Females had both thoughts and attempts higher as compared to males. Sudhir Kumar has reported increased incidence of adolescent suicide world over and its relation to stressful life event in the recent past. Senseman reported schizophrenia as most common psychopathology in adolescents attempting suicide. The establishment of a 'Crisis Center' or a suicide prevention center in the major cities of India should be an urgent undertaking. A telephone answering service manned by volunteer person 24 hours a day throughout the year would be of great value.[32,33]
CASE REPORTS
Considerable number of interesting case reports has been published. Some of them are:
Title of the study
Effectiveness of fluoxetine in the treatment of skin picking: Due to its similarities between OCD and impulse control disorder, skin-picking and related behaviors have been reported to span a compulsivity-impulsivity continuum from the purely obsessive- compulsive to the purely impulsive, with mixed symptoms in between. This case report highlights the effectiveness of fluoxetine in the treatment of skin-picking and the need for early institution of treatment, which would not only curtail the period of suffering but ensure long-lasting improvement in such cases.[34]
Management of trichotillomania: Treatment package of combination of pharmacotherapy and behavior therapy showed significant improvement. Various other studies explored insight oriented psychotherapy, cognitive- behavioral therapy but documented three studies in this report showed very encouraging results in managing this disorder of impulse control.[35]
Conduct disorder: A sequelae of viral encephalitis: Hyperactivity and oppositional behavior in children are common post encephalitis sequelae. Some of the great neuropsychiatrists of the past described the behavioral and temperamental changes that can occur following VE.[36]
Rett's Syndrome: Increased identification will help in greater understanding of Rett's Syndrome and proper guidance will help to reduce the burden of care on the parents.[37]
Clozapine in pregnancy: Like other psychotropics clozapine should be used with caution during pregnancy as there is insufficient knowledge regarding clozapine-induced agranulocytosis in fetus/neonate.[38]
Somnambulism: Diagnosis and treatment: Careful noting of case history and epilepsy is an important differential diagnosis. Treatment is considered when frequency of events is high, psychosocial complications or stressors are present or when events are violent and potentially injurious. A low-dose benzodiazepine is the drug of choice, although tricyclic antidepressants and trazodone may be beneficial as well. Behavioral management in the form of scheduled awakenings and a positive bedtime routine along with appropriate interventions are essential.[39]
A case of early infantile Autism: The case was diagnosed as early infantile autism with cerebral palsy and mental defect on the basis of the peculiar behavior and language, echolalia and mutism.[40]
A case of Kleine Levine Syndrome: The case reported fitted into the diagnostic criteria of Critchley and Hoffman (1942) with respect to age of onset and periodic attacks of excessive sleep and eating. Long term follow-up supported the diagnosis of it as the unmistakable case of Kleine Levine Syndrome.[41]
An unusual variant of Hallerman Streiff Syndrome: Case differed from the classical Hallerman Streiff in having no ophthalmological problems which is a common finding and in having chromosomal anomaly, but many other features like mandibulo-oculo-dyscephaly making it an unusual variant. Presence of Psychosis was also an uncommon occurrence. Possible emergence of new syndrome was considered.[42]
Treatment-refractory, juvenile-onset bipolar affective disorder: The cumulative incidence of bipolar disorder in childhood and adolescence may equal the 1% rate in adults. An 18-year-old girl diagnosed with bipolar affective disorder was given trials with various mood stabilizers as a monotherapy and combination therapy for current episode. Treatment resistant status led to initiation of clozapine with which patient stabilized within 4 weeks on 200 mgs. Patient maintained remission during next 2 years of follow-up. The natural history and management of juvenile bipolar disorder present more questions than answers.[43] CONCLUSIONS
It was not possible to cover all the topics and articles published in Indian Journal of Psychiatry on child and adolescent mental health in the last five decades. There are 118 original articles, 21 case reports, six editorials, five presidential addresses and one oration dealing with the subject. It is our humble suggestion to refer to large number of books written by Indian psychiatrist, psychologist and social workers on child and adolescent mental health. Apart from English, large number of publications on the area is in vernacular languages. It is advisable to search Indian research material from various other sources like IAPP Journal, IACAM Biannual reports, Indian Journal of Pediatrics and Indian Journal of Preventive and Social Work. Large numbers of services are primarily multidisciplinary; other team members publish their work in their respective association journals. There are specialized groups which function independently with their own association like Down's syndrome Association, Spastic Society, Society for mentally handicap children, Dyslexia association and national forum for autism.
REFERENCES
1. Shastri PC. Future Perspective of planning child guidance services in India. Indian J Psychiatry 2008;50:241-3. 2. Bartlet LB. Child psychiatry in India-A western view. Indian J Psychiatry 1983;25:63-6. 3. Malhotra HK. Public opinion and the Child Guidance Clinics in India. Indian J Psychiatry 1977;19:14-9. 4. Shastri PC. Promotion and prevention in child mental health. Indian J Psychiatry 2008;51:88-95. 5. Chawla P. A study of prevalence and pattern of hyperactive syndrome in primary school children. Indian J Psychiatry 1982;23:313-22. 6. Bhargava SC. Sleep disorders in children with attention-deficit hyperactivity disorder. Indian J Psychiatry 2005;47:113-5. 7. Pain B. The child rearing attitudes of the parents of (male and female) schizophrenics. Indian J Psychiatry 1982;24:147-54. 8. Mukerji M. Parent personality and adolescent maladjustment. Indian J Psychiatry 1973;15:29-31. 9. Wig NN. Parental deprivation and mental illness: A study of the incidence of parental death in childhood in 2000 psychiatric patients. Indian J Psychiatry 1969;11:1-6. 10. Bagadia VN. Significance of paternal and maternal loss in mental illnesses. Indian J Psychiatry 1976;18:59-65. 11. Guha P. Behavior profile of children with nephritic syndrome. Indian J Psychiatry 2009;51:122-6. 12. Sathyanarayana Rao TS. Criminal behavior: A dispassionate look at parental disciplinary practices. Indian J Psychiatry 2007;49:231-2. 13. Sarkhel S. Prevalence of conduct disorder in schoolchildren of kanke. Indian J of Psychiatry 2006;48:159-64. 14. Malhotra S. Specific developmental disorders in children attending a child guidance clinic. Indian J Psychiatry 1987;29:343-7. 15. Malhotra S. Incidence of childhood psychiatric disorders in India. Indian J Psychiatry 2009;51:101-7. 16. Narayanan HS. A clinical survey of 1200 cases of mental retardation with a brief report of some very rare types. Indian J Psychiatry 1973;15:143-6. 17. Chaturvedi SK. A follow-up study of mental retardation focusing on parental attitudes. Indian J Psychiatry 1984;26:370-6. 18. Rastogi CK. Attitudes of parents towards their mentally retarded children. Indian J Psychiatry 1981;23:206-9. 19. Somasumdaram. Behaviour Characteristics Of The mentally retarded in a state mental hospital - A comparative study. Indian J Psychiatry 1984;26:115-20. 20. Venkobarao A. A report of observations made during a collaborative biochemical screening of mentally retarded children investigated at madurai and Bangalore. Indian J Psychiatry 1970;12:273-7. 21. Sharma SN. Neurotic disorders in children: A psychosocial study. Indian J Psychiatry 1980;22:362-5. 22. Manchanda M. Neuroses in Children: Epidemiological aspects. Indian J Psychiatry 1987;20:161-5. 23. Trivedi JK. A clinical study of hysteria in children and adolescents. Indian J Psychiatry 1982;24:70-4. 24. Teja JS. The child with speech problem. Indian J Psychiatry 1972;14:207- 11. 25. Desai G. More questions than answers! Clinical dilemmas in psycho pharmacology in pregnancy and lactation. Indian J Psychiatry 2009;51:26- 33. 26. Sringeri R. The association between attention-deficit hyperactivity disorder and early-onset alcohol dependence - A retrospective study. Indian J Psychiatry 2008;50:262-5. 27. Bansal R. Substance use by child laborers. Indian J Psychiatry 1993;35:159-61. 28. Gossp M. Preventing and controlling drug abuse. Geneva: WHO; 1990. p. 5-18 and 29-33. 29. International Labour Organization. Still so far to go: Child labour in the world today. Geneva: International Labour Organization, 1989. 30. International Labour Organization. Child Labour: Law and practice. Conditions of work digest, 10 Geneva: International Labour Organization, 1989. 31. Malhotra S. Study of Childhood onset schizophrenia using SPECT and neuropsychological assessment. Indian J Psychiatry 2006;48:215-22. 32. Sudhirkumar CT. A study of psychosocial and clinical factors associated with adolescent suicide attempts. Indian J Psychiatry 2000;42:231-42. 33. Senseman L. A U.S. study of attempted suicide in Adolescents. Indian J Psychiatry 1971;13:29-36. 34. Sharma RC. Effectiveness of fluoxetine in the treatment of skin-picking. Indian J Psychiatry 2005;47:241-2. 35. Kaur H. Management of Trichotillomania. Indian J Psychiatry 2005;47:235-7. 36. Deka K. Conduct Disorder- A sequelae of viral encephalitis Indian J Psychiatry 2006;48:258-9. 37. Sitholey P. Rett's Syndrome. Indian J Psychiatry 2005;47:116-8. 38. Sethi S. Clozapine in Pregnancy. Indian J Psychiatry 2006;48:196-7. 39. Bharadwaj R. Somnambulism: Diagnosis and treatment. Indian J Psychiatry 2007;49:123-5. 40. Bassa DM. A case of early infantile autism. Indian J Psychiatry 1962;4:73-6. 41. Narayanan HS. A case of Kleine-Levine Syndrome. Indian J Psychiatry 1972;14:356-8. 42. Narayanan HS. An unusual variant of Hallermann-streiff Syndrome. Indian J Psychiatry 1985;27:159-62. 43. Sagar V. Treatment-refractory, juvenile-onset bipolar affective disorder. Indian J Psychiatry 2005;47:124-5.
Priyavadan Chandrakant Shastri Diploma International Culture (USA), FWAI; Department of Psychiatry, B.Y.L. Nair Hospital and Topiwala National Medical College,
Jay P. Shastri Convenor, Child Psychiatry IPS-WZ, Honorary Professor: Sir Kikabhai Premchand's MIND's College of Special Education Dimple Shastri Shrimati Motibai Thakersey Institute for Research in field of mental retardation, Child Development Center, Honorary Lecturer: Sir Kikabhai Premchand's MIND's College of Special Education Philip: Learning and other developmental disorders in India 34 Learning and other developmental disorders in India
John Philip
ABSTRACT
Articles that include Learning and Developmental Disorders have been gathered from the Indian Journal of Psychiatry archives, and are broadly discussed. Learning disorders (LD) are not pure syndromes. They are developmental disorders and are multi-dimensional in nature. Research areas in Child Psychiatry in India remain largely unexplored, especially developmental disorders. The potential for research is mind boggling. Original research must keep pace with work in the west, and must be of a high order. Results must be published in our national journal and not abroad, in order to bestow prestige to our journal, so the world can sit up and take notice.
Key words: Child Psychiatry, developmental disorders, Indian Journal of Psychiatry, learning disorders
INTRODUCTION
"Humans were not born to read, or to write". (Rosemary Tannock)
Annotations are explanatory notes; the editor's brief to me was to review articles pertaining to Learning Disorders that were published in the IJP. These have been abysmally few, yet many studies allude to these disorders. The passionate editorial by T.S.S. Rao and V.S.T. Krishna on "Stars on the Ground"[1] and the Clinical Practice Guidelines for Specific Learning Disorders by Nilesh Shah and Tushar Bhat"[2] are exceptions.
For obvious reasons, outstanding or original studies by psychiatrists done in India used to get published abroad or in various national journals.; or, if they failed to replicate western thoughts, they did not get published at all. We seem to live in reverential wonder of the western thinking (which maybe fine), but often refuse to contemplate out of that box. More than a decade ago, some of us thought that Asperger's syndrome may be a high-functioning autistic disorder, and later, that obsessive disorder in childhood, unlike adult obsessive compulsive disorder (OCD), may be developmental in origin. These thoughts could not then cross the peer-review barrier, as our fraternity was bound by western concepts; yet today we so willingly accept them! The absence of publication of original studies in our Indian journal not only takes away the prestige of the journal, but also puts us a step behind the west every time.
For the amount of replications of western studies that we do, whether they are epidemiological methods or 'standardizing' instruments, such articles must not make us feel like the footslogger trying to catch up with the running car.
Do deliver old wine in new bottles
We, in India, have been apologetic of examining our traditional concepts to present them as concrete paradigms for prevention or management of disorders. If cognitive behavior therapy can be a concrete management strategy, so can the doctrines of the Bhagwat Gita, provided we can formulate them as a concrete strategy through appropriate research studies. It is one of the most successful paradigms for restructuring cognition even during brief contact with patients, whether children on the eve of their exams, or adults after failing to get a coveted promotion. In Anxiety, or in Depression. The simplicity of its application even for the patient whose metacognition is poor, is its true strength.
Or for that matter, look at our traditional Hierarchical Parenting strategies. Parenting by keeping a personal space teaches our children discipline without having to punish, tolerance without having to bribe, respect without having to yell or scream. This hierarchical parenting package can build capacity in our children for tolerance to frustration, tolerance to criticism, and a tolerance to change. It can teach them the strength of internal discipline, which has been the traditional Indian wisdom. However, such parenting is today rebuked and ridiculed by many of us because it is not 'stylish', not acceptable to the metropolitanism of our media, and inimical to the western family percept! Instead of raving and rhapsodizing about the non-hierarchical strategy of 'father being a friend', has any of our researchers undertaken to prove or disprove the value of hierarchical parenting without punishing, and offer it as a paradigm for inculcating discipline in children? (This is the opportune time to study the effectiveness of our hierarchical parenting and present it to the world, when the west is smarting under the downturn of their financial and disciplinary systems with the failure of hierarchical governance).
All these can become original studies from India, based on generations of replicability, which is what science is about. I am certain these strategies can catch up as 'packages' like yoga and meditation, if we can put them across in our journal after scientific studies with individuals and families, based on rational research methodology.
Need for drawing up research initiatives in developmental disorders
Let me sum up my prefatory frustrations. We acknowledge the enormity of the responsibility of our fraternity working with children, if they have to start original or serious replicative research. This nascent sub-speciality of Child Psychiatry needs to examine 'Developmental Disorders,' including Learning Disorders, for research, in a big way, because of the sheer force of the number of children in our country who suffer silently from these 'silent handicaps'.
We need to look at these disorders from an Indian standpoint, and initiate independent research in their Psychopathology and Phenomenology, Nosology and Diagnosis, Epidemiology and Distribution, Etiology and Pathogenesis, and Methods of Management; furthermore, in major centers, their Genetics and Neuroscience. If major centers have this wisdom and the initiative, we need not become footsloggers in research.
Editorials and presidential columns
There is a recent spurt of interest in child psychiatry. T.S.S. Rao's moving editorial in early 2008,[1] followed the release of Aamir Khan's movie, 'Taare Zameen Par'. Rao and Krishna have pondered over several facets of Learning Disorders, the agony of the affected child, and the failure of the family and the schooling system to identify and manage these disorders. Today's performance-oriented society too comes under their scrutiny, and they raise contemporary issues of adolescent suicide. I have, however, grave concerns when we merely point fingers at the pressure of the education system for academic achievement. The past three decades of experience have taught me to consider the present-day children's inability to tolerate frustration and criticism as a major culprit and not merely condemn well-meaning parents and teachers. In which case, non-hierarchical, poor-disciplining parenting, or autocratic parenting may be the malefactor. Discipline is not meant to be synonymous with punishment; but it provides the skill of adaptability and resilience. However, this needs evidence-base and appropriate research.
P.C. Shastri never misses an opportunity to call upon the society and the medical fraternity to focus on life, survival, mental health, and basic education of children in our country. He has eloquently, using demographic data and extensive statistics, argued for a national comprehensive policy in his Presidential columns in the April and October 2008 issues of IJP.[3,4] His article on planning child guidance services in India envisages developing about 10,000 CGCs for the entire country to deal with developmental and other psychiatric disorders in children.
The Presidential address by P.C. Shastri on 'Promotion and prevention in child mental health' in January 2009,[5] elaborates on a National Action Plan for child mental health, based on the concept of a 'single window operation' in every district.
Conceptual metamorphoses across decades
After perusing the IJP articles of the 1980s on Developmental Disorders, which look at the mere psychosocial etiopathogenic concepts of developmental disorders, including 'Learning Disability', it is incredible to examine where the neurosciences of these disorders stand today.
In an investigation of 100 cases of learning disabilities by S. Khurana in 1980,[6] the implications were that causation of this difficulty was dependant on a disturbed relationship with the father, impaired relationship at school, fear of the teacher, fear of school, greater pressure of achievement on boys, causing greater disability in boys, disability being 'essentially urban', and that this disability and other problems such as enuresis and stammering 'are results of traumatic experiences' in the school and so on and so forth. Bapna and Ramanujam, in 1976, had drawn similar conclusions emphasizing the parent–child relationship.[7]
Currently, everyone of these assertions has been proved wrong by the exponential technology that peeps into live brain cells as they go about performing various mental functions.[8] Today, the concepts related to 'hyperactive', 'hyperkinetic', and 'MBD syndromes' appear as empiricisms in retrospect, when one reads through articles by P. Chawla[9] and Baldev K et al.[10]
Today, research using cutting-edge technology uncovers both the morphology and function of various parts of the brain, to reveal how psychiatric disorders occur in children. It enables us to comprehend how two dynamic processes – synaptic pruning and myelination – continue from early childhood through adolescence and keep modulating cognitive and social skills, and behavior.[11] It should be possible for research in developmental disorders in India to operate at this level, and for such research to be published in IJP. Intellectual disability (Mental Retardation)
All developmental disorders tended to be 'stigmatizing disabilities'. Our field has now moved to change the name of 'Mental Retardation,' replacing it with 'Intellectual Disability,' perhaps to de-stigmatize the term, and to give precision to the term.[12]
In India, considerable focus has been paid to Intellectual Disability (Mental Retardation) and its various aspects, although not much on its management.[13] Other developmental disorders such as Specific and Pervasive developmental disorders have not found much space in IJP, although the potential is enormous.
Learning disorders
Humans were not born to read, or to write.[14] Oral language skills originated a hundred thousand years ago, but reading as we know came about only a few thousand years back. If the creator did not allocate a place in the beginning, how did the brain then acquire it? Neuroplasticity, of course, is what made it possible, within whatever cells were given for the function of language. Multiple skills are involved in learning to read the spoken sounds that get mapped into the left brain as written symbols, letters, and thus words that mean something. Reading comprehension, the process of understanding automatically as we read is the extraction of meaning from written language.[14] This extraction of meaning through reading is not possible in children with learning disorders, especially reading disorder.
'Listening' comprehension is excellent in the LD child, though he cannot 'read' and comprehend; he can answer the teacher's question orally, but cannot write the same. Hence, the axiom that the 'LD child would be the smartest lad in the whole school if instruction were entirely oral!'
From the neural findings, there is a current consensus among researches that the central problem in Learning Disorders reflects a core deficit in the Language system.
Similarly, attention as in Attention-Deficit Hyperactivity Disorder (ADHD), was not seen as a deficit in learning disorders, until recently. Today several lines of evidence — behavioral, genetic, and neuroimaging studies — show that attention mechanisms play an active role in reading and reading comprehension.[14] Learning disorders, therefore, are not pure syndromes.
Our experience at Cochin, with over five thousand children assessed for poor school performance (PSP) on a hierarchical multidisciplinary model, has given us the strength to posit 'a spectrum-construct' of developmental disorders.[8] An unusually high degree of co-existence of all these developmental disorders together, along with conditions such as ADHD, obsessive / obsessive spectrum disorder, as well as a pattern of presentation that is increasingly showing a stereotype encouraged us to approach these disorders as a 'mixed-bag' initially, and now as possibly the 'unitary-bag'.[15]
Our current understanding tells us that the neural processes involved in learning to read, write, spell, and perform maths themselves change and develop the brain cells both physiologically and functionally. Therefore, all the above academic skills are obviously neurally interconnected along with the core circuits in the language and attentional systems. We, therefore, need to look at the 'connectivity deficit' in the entire basket of developmental disorders, which percolates into our daily clinical practice. Concepts of these disorders have truly metamorphosed.
This explanatory note was to indicate that learning disorders cannot be seen in isolation, either for diagnosis or for management. Every learning disorder may not constitute a 'disability'. Hence my title, 'Learning and other Developmental Disorders'. Furthermore, we know here today that these disorders even respond to interventions, including pharmacological ones.
Changes in operational definition of LD
A loosening of definition criteria for Learning Disorders (LD) seems to be taking place; the Federal definition of LD adopted by the US Office of Education (to determine eligibility for special education) has drastically changed concepts.[14] The recent changes are of great relevance to psychiatrists.
The clinical definition of LD denotes a significant impairment in the acquisition and use of the academic skills of reading, writing, spelling, and arithmetic, in the background of the child having normal or above-normal intelligence. This connotes a discrepancy factor, a severe discrepancy between the child's intellectual ability and his achievement on paper. At present, this definition also applies to it being life-long, assuming that there is no response to intervention (RTI). As against the DSM definition, two basic components have drastically changed now in the Federal definition: i) There is no requirement for the discrepancy factor anymore in the US Federal regulation, that is, there need not be a discrepancy between intellectual ability reflected by IQ and the child's achievement, but, ii) the federal regulation stipulates that the child be given quality intervention upon diagnosis; state sponsored Special Education will be only for those children who do not respond to this intervention (RTI)!
Nosological shifts
In DSM III and DSM IIIR, all Academic Skills Disorders were classified under Axis II, they being developmental. DSM IV-TR now codes these on Axis I under clinical disorders. This may be quite significant for clinicians like us; the current definitions in DSM IV-TR recognize the multi-dimensional nature of these developmental disorders.
The other very significant shift in DSM is that of Communication Disorders (developmental disorders of language) and Motor Skill Disorders (developmental co-ordination disorders) from Axis II in DSM IIIR, to Axis I in DSM IV. I reckon this opens up greater pharmacotherapeutic and prognostic possibilities for clinicians who think like we now do.
Child psychiatric epidemiology in india
A very significant attempt to synthesize available research on the prevalence of child psychiatric disorders, and highlight methodological trends was undertaken by P. Bola and M. Kapur[16] They evaluated 55 epidemiological studies conducted between 1964 and 2002, in the community and school settings. This one review made my job so much quicker and shorter, as most of the important epidemiological study in this field had been covered by the authors. It even included my MD thesis work[17] that used, as in most studies, a Children's Behavior Questionnaire (CBQ), and a clinical interview. As could be expected, the prevalence rates were very varied within the community- based and school-based studies. This meticulously written article is a lesson in critical appraisal of the epidemiological studies.
I must use this occasion to pay tribute to the Late Prof. R.L. Kapur, and Dr. Malavika Kapur for the thorough, painstaking, and uncompromising methodology in their research study; 'The Great Universe of Kota' is a living testimony.
The study of Malhotra S. et al., in the epidemiological research methodology and in the development of instruments has been significant. Their recent study on 'incidence' of childhood psychiatric disorders in India'[18] is a longitudinal study, taking off from their well known 2002 prevalence study. These studies have differentially diagnosed learning disorders. CONCLUSION
The core concepts about all developmental disorders seem to be drastically changing with the gathering evidence of genetic studies, with gene loci, pharmacogenomic studies, vigorous research in neural sciences, and evidence-based investigations for pharmacotherapy in these disorders. The multidimensional nature of these disorders is evident from research as well as clinical studies. The 'spectrum-construct' seems to enable pharmacological options for therapeutic intervention, along with the regular multi-pronged, non-pharmacological options.
This sojourn from the times of psychodynamic empiricism in child psychiatry to the current application of basic neurosciences to children's day-to-day problems, from the twentieth century to the twenty-first century, has been remarkably worth its while. Now we require structured research and publication in IJP. Long Live IJP!
ACKNOWLEDGMENT
I wish to thank Dr. Johann Philip, Postgraduate Resident in Psychiatry, Sri Ramachandra University, Chennai, for his assistance with accessing and compiling the data base, and enabling the review.
REFERENCES
1. Rao TS, Krishna VS. Wake up call from 'Stars on the Ground'. Indian J Psychiatry 2008;50:2- 4. 2. Shah N, Bhat T. Clinical practice guidelines for the specific learning disorders. Indian J Psychiatry 2009;51:68-95. 3. Chandrakant SP. Child in India. Indian J Psychiatry 2008;50:85-6. 4. Shastri PC. Future perspective of planning child guidance services in India. Indian J Psychiatry 2008;50:241-3. 5. Shastri PC. Promotion and prevention in child mental health. Indian J Psychiatry 2009;51:88-95. 6. Khurana S. Non-intellectual factors in learning disability. Indian J Psychiatry 1980;22:256- 60. 7. Bapna G, Ramanujam BK. Clinical study of learning inhibition. Indian J Psychiatry 1976;18:14. 8. Philip J. Boundary debates: The new challenge of Psychiatry. Indian J Psychiatry 2010;52:106-9. 9. Chawla PL, Sahasi G. A study of prevalence and pattern of hyperactive syndrome. Indian J Psychiatry 1982;23:313-22. 10. Baldev K, Jain X, Manchanda SS. Behavioral disorders of childhood and adolescence. Indian J Psychiatry 1972;14:213. 11. Pataki CS. Child Psychiatry. In: Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p. 3335-7. 12. King BH, Toth KE, Hodapp RM. Intellectual Disability. In: Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p. 3444. 13. Narayanan HS. A clinical survey of 1200 cases of mental retardation with a brief report of rare types. Indian J Psychiatry 1973;15:143-6. 14. Tannock R. Learning Disorders. In: Sadock BJ, Sadock VA, Ruiz P, editors. Comprehensive textbook of psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p. 3335-7. 15. Philip J. Co-morbid disorders in learning disabled children. In: Karanth P, Rozario J, editors. Learning Disabilities in India. Delhi, London: Sage Publications; 2003. p. 44-50. 16. Bhola P, Kapur M. Child and adolescent psychiatric epidemiology in India. Indian J Psychiatry 2003;45:208-17. 17. Philip J. Psychiatric morbidity in school children. Unpublished MD thesis, NIMHANS, Bangalore. 1980. 18. Malhotra S, Kohli A, Kapoor M, Pradhan S. Incidence of childhood psychiatric disorders in India. Indian J Psychiatry 2009;51:101-7.
John Philip Peejays Child Guidance Clinic, Cochin, S. India and CGC, Sharjah, UAE Chadda and Sood: Women and psychiatry 35 Indian research on women and psychiatry
Rakesh K. Chadda, Mamta Sood
ABSTRACT
The paper discusses research on various issues related to mental health specific to women, published mainly in the Indian Journal of Psychiatry. We carried out a manual search of all the issues of the journal. Indian psychiatrists have worked in a wide range of areas including psychological aspects of different reproductive phases like pregnancy, puerperium, menopause, menstrual cycle, psychological consequences of contraception, infertility and surgical loss of uterus or breast. Most of the studies are cross sectional with very few prospective studies. There is a need for longitudinal, epidemiological and intervention studies.
Key words: Women and Psychiatry, reproductive phases and mental health, family planning and mental health
INTRODUCTION
Gender has been described as a critical determinant of mental health and mental illness.[1] The specialty of gynaecology and obstetrics in medical science exclusively caters to the specific health needs of the women, whereas there is no such exclusive medical discipline for men. The reproductive system of women also follows a unique biological rhythm and their body undergoes specific changes with different cycles of reproduction, both anatomical as well as physiological. Menarche, puberty, menstrual cycle, pregnancy, puerperium and menopause are specific life events of a woman's life. These phases are associated with different kinds of stress; and if a woman is not able to cope with the changes or if the social support systems fail, she may develop mental health problems.
Gender differences in mental disorders have been reported, particularly, in the prevalence of common mental disorders including depression, anxiety disorders and somatoform disorders.[2,3] Depression is not only the most common women's mental health problem but may be more persistent in women than men. However, alcohol dependence, another common disorder, is twice more common in men than in women. Men are also three times more likely to be diagnosed with antisocial personality disorder than women. There are no marked gender differences in the rates of severe mental disorders like schizophrenia and bipolar disorder that affect less than 2% of the population, though some differences have been reported in age of onset of symptoms, frequency of psychotic symptoms, course of these disorders, social adjustment and long term outcome. Thara and Rajkumar[4] have reported better course and outcome in women in schizophrenia as compared to men.
Higher rates of depression, anxiety and somatic symptoms are related to a range of risk factors such as gender-based roles, stressors and negative life experiences and events. Gender specific risk factors for common mental disorders that disproportionately affect women include gender-based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank, and unremitting responsibility for the care of others. [3,5] There is a positive relationship between the frequency and severity of such social factors, and the frequency and severity of mental health problems in women. Severe life events that cause a sense of loss, inferiority, humiliation or entrapment can predict depression. Women are often exposed to sexual violence which leads to high rates of post traumatic stress disorder (PTSD) following such violence.
Psychiatric conditions seen exclusively in women include those seen in association with various phases of the sexual maturation or reproductive phases like pregnancy, menstrual cycle, puerperium, breast feeding, mothering and menopause, and surgical procedures related to specific female organs like mastectomy and hysterectomy.[1]
This paper discusses research on psychiatric problems seen in women, published mainly in the Indian Journal of Psychiatry. A manual search of all the volumes of the Indian Journal of Psychiatry was carried out. We were able to identify two presidential addresses[6,7] one editorial,[8] 19 original papers, four case reports and one oration,[9] which have discussed exclusively women related mental health issues.
Indian psychiatrists have studied psychiatric morbidity in women in primary care settings, mental health abnormalities associated with various phases of reproductive cycle like menstrual phases, pregnancy and postpartum period, psychiatric aspects of contraception and medical termination of pregnancy, infertility and hysterectomy, and teratogenecity. Important research findings are discussed below.
Psychiatric morbidity in women in primary care
In a recent study on psychological symptoms in rural women from Tamil Nadu, Lawson et al.[10] reported an association between caseness on self report questionnaire (SRQ) and poverty. Domestic violence, alcoholism in husbands, physical illness, pain symptoms, increasing age and having more than two children increased the probability of caseness. Suicidal ideation was reported by nearly half of the sample. Increasing age, being a widow, higher number of children and physical illness in a family member were important contributory factors. However, the study had a major limitation of not including psychiatric assessment in the design.
Mental health problems associated with different reproductive phases in women
Menstrual cycle and mental health
Many Indian psychiatrists have attempted to explore the emotional changes and disturbances in relation with different phases of menstrual cycle;[9] the pre menstrual phase has been found to be associated with emotional distress. In an ICMR supported study on suicide attempters, Prof A Venkoba Rao and Prof S Parvathi Devi in 1972[11] found that 64% of the attempters had made attempts during the pre menstrual phase or early menstrual phase. Marital status was not found to be an influencing factor. The authors explained the findings in term of pre menstrual depression and psycho endocrine imbalance during the period.
Professor Abraham Varghese way back in 1963[12] reported a case of pre menstrual psychosis, a rare disorder, in a 26-year-old lady, in whom psychotic symptoms would appear every time during the pre menstrual phase and would be relieved completely with the onset of menstrual bleeding. The symptoms sometimes would last for periods up to 2 weeks, but were not long standing. At times she had required hospitalization in a state mental hospital and was given ECT for the symptoms. Shah et al.[13] reported a case of menstrual psychosis, in which the psychotic disturbance had onset in the pre- menstrual phase and would continue for two to three weeks. Later investigations revealed low progesterone levels in the follicular phase of the menstrual cycles.
Pregnancy and post partum period
Pregnancy and post partum period have also attracted the attention of many psychiatrists. There have been both prospective as well as cross sectional studies. In a cross sectional study on phenomenology of post partum psychiatric phenomena by Gautam et al.[14] in early 1980s from Jaipur, 67% of the patients seen in a psychiatric setting were found to suffer from schizophrenia and 25% from affective psychosis as per ICD 9 criteria, implying that only patients with severe disturbance are likely to reach the psychiatric settings. Sixty six per cent of the cases were primipara.
In a prospective study conducted more than 30 years ago at Vellore, John et al.[10] followed up 59 women from the last trimester to the post partum period. Twenty four per cent of them developed depression requiring intervention. Women having higher neuroticism score and those who were more particular about the sex of the baby were more likely to develop depression. Age, parity, family structure, complications during pregnancy and sex of child were not found to have any relationship with tendency to develop depression. In another prospective study on depression during late pregnancy and post partum period conducted in an army hospital setting by Sood and Sood,[16] about 10 years ago, prevalence of depression as measured using the Beck Depression Inventory was 8.3%, 20.0% and 12.8% during the third trimester, three days after delivery and eight weeks after delivery respectively. Incidence was 16% and 10% in early and late post partum periods respectively. Depression during late pregnancy was found to be associated with depression occurring in early post partum period, but not with the late post partum period.
Menopause
Women in menopause have been found to suffer higher psychological morbidity as compared to pre menopausal and post menopausal women.The predominant psycho pathology is from depressive spectrum.[17] Various menopausal symptoms reported in Indian settings include physical or mental exhaustion, irritability, depressed mood, decreased sleep and decreased interest in sex. [17,18]
Family planning and mental health
Increasing population of India has been a major concern with the Government and the health planners, which led to the launch of family planning program in 1960s. Various activities undertaken in the family planning program have been associated with mental health consequences, which have also been the focus of mental health professionals. Mental health aspects of family planning were the topic of an editorial in 1981 by late Professor B.B. Sethi. [8] Contraception and medical termination of pregnancy (MTP)
Tubectomy, one of the common methods of contraception, has been reported to be followed by three sets of symptoms: menstrual, psychological and sexual.[19] There is a wide variation in the frequency of the latter two categories of symptoms, varying from 1.5-83%. Anxiety, depression, memory impairment and somatic complaints are common psychological sequelae.[8,19] Psychological symptoms are less frequent after MTP as compared to those seen after tubectomy or vasectomy. Intrauterine contraceptive devices, however, have not been found to be associated with psychological symptoms.[20] In a study of rejecters and acceptors of MTP amongst women with psychiatric problems, who were advised termination of pregnancy on medical grounds during the first trimester, acceptors were from higher education and socioeconomic background. Age, marital status, number of children, and nature of illness were not found to influence the decision to consent for MTP. Outcome of psychiatric illness was found to be better in the acceptors of MTP than the rejecters. [21]
Infertility
Psychological consequences of infertility have also been investigated. In a controlled study, Thara et al.[22] found that couples suffering from infertility suffer more psychological symptoms like depression and anxiety and also psychosexual dysfunction. The males suffer erectile dysfunction and premature ejaculation, whereas the females suffer vaginismus, dyspaerunia and sexual dysfunction.
Surgeries related to women specific organs
Uterus and breast are two unique organs of women, which are associated with female image and are also vital for reproduction and mothering. Both the organs are prone to cancer and their loss is associated with psychological and social consequences as well as important physical implications because of the seriousness of the illness and importance of the two organs in a woman's body image, sexuality and motherhood. There have been a few studies on the topic in India.
In a prospective study of psychiatric complications of hysterectomy, Subramaniam et al.[23] conducted a one-year follow up of 50 women who had undergone hysterectomy. Twenty per cent of the patients developed psychiatric problems, mainly depression, Whereas only one of the 20 controls developed hysterical reaction. Patients who had developed depression had higher scores on neuroticism even before hysterectomy than those who did not develop any psychiatric problem. Patients who had undergone hysterectomy reluctantly had higher risk of developing psychiatric symptoms than those who had undergone surgery willingly. The authors concluded that patients undergoing hysterectomy need to be prepared properly and counseled so as to prevent psychiatric complications.
Mastectomy is the other major surgery, which women may have to undergo. Following mastectomy, a woman may experience a range of concerns and fears related to physical appearance and disfigurement, uncertainty about recurrence and the fear of death. Mahapatro and Parkar [24] studied psychological consequences in women who had undergone mastectomy or lumpectomy for breast cancer. Mastectomy is a more radical procedure than lumpectomy. They found concerns with body image or disfigurement only in mastectomized group. The concerns about the illness and after effects were generally resolved in both the groups except for sexual role and performance, which were resolved to a lesser extent in the mastectomized group. The two groups suffered similar levels of anxiety and depression. The authors concluded that the concern regarding sexual role and performance are resolved to a lesser extent in the mastectomized group and specific psychological intervention is required for them to enhance their coping strategies with regard to concerns of body image, and sexual role and performance
CONCLUSION
Indian psychiatrists have investigated a wide range of mental health problems in women including those occurring during pregnancy and puerperium, psychological effects of contraception, MTP, hysterectomy and mastectomy, suicide, relationship between domestic violence and mental health, suicidal behavior and epidemiological trends. Prospective and intervention studies are generally lacking.
REFERENCES
1. World Health Organization. Nations for Mental Health: A Focus on Women. World Health Organization: Geneva, 1997. 2. World Health Organization. Women's Mental Health: An Evidence Based Review World Health Organization: Geneva, 2000. 3. Patel V, Araya R, de Lima MS, Ludermir A, Todd C. Women, poverty and common mental disorders in four restructuring societies. Soc Sci Med 1999;49:1461-71. 4. Thara R, Rajkumar S. Gender differences in schizophrenia, Results of a follow-up study from India. Schizophr Res 1992;7:65-70. 5. Kumar S, Jeyaseelan, Suresh S, Ahuja RC. Domestic violence and its mental health correlates in Indian women. Br J Psychiatry 2005;187:62-7. 6. Malik SC. Presidential address: Women and mental health. Indian J Psychiatry 1993;47: 3- 10. 7. Nambi S. Presidential address: Marriage, mental health and the Indian legislation. Indian J Psychiatry 2005;47:3-14. 8. Sethi BB. Editorial: Family planning and mental health. Indian J Psychiatry 1981;23:101-3. 9. Chandra PS. Interface between psychiatry and women's reproductive and sexual health. Indian J Psychiatry 2001;43:295-305. 10. Lawson E, Craig T, Bhugra D. Psychological symptoms in women in a primary care setting in Tamil Nadu. Indian J Psychiatry 2005;47:229-32. 11. Devi SP, Rao AV. The pre menstrual phase and suicidal attempts. Indian J Psychiatry 1972;14:375-9. 12. Verghese A. The syndrome of pre menstrual psychosis. Indian J Psychiatry 1963;5:160-3. 13. Shah A, Vahia VN, Yadav R, Sonavane SS. Menstrual psychosis: A case report. Indian J Psychiatry 2003;45(2):41-42. 14. Gautam S, Nijhawan M, Gehlot PS. Post partum psychiatric syndromes: An analysis of 100 consecutive cases. Indian J Psychiatry 1982;24:383-6. 15. John JK, Seethalakshmi, Charles SX, Verghese A. Psychiatric disturbance during the post partum period: A prospective study. Indian J Psychiatry 1977;19(4):40-3. 16. Sood M, Sood A. Depression in pregnancy and post partum period. Indian J Psychiatry 2003;45:48-51. 17. Prakash IJ, Murthy VN. Psychiatric morbidity and menopause. Indian J Psychiatry 1981;23:242-6. 18. Sangale J, Faye A, Kokate A, Avinas P, Subramanyam A, Shah H, Kamath R. Psychological symptoms and quality of life in menopausal women (Abstract). Indian J Psychiatry 2009;51:S124-S125. 19. Wig NN, Kaur R, Pasricha S, Devi PK. Psychological sequel of medical termination of pregnancy. Indian J Psychiatry 1978;20:254-61. 20. Sharma RG, Bhaskaran K. Attitude study of IUCD from psychiatric point of view. Indian J Psychiatry 1968;10:12-6. 21. Dash PS, Dash B. A comparative study of acceptors and rejecters of psychiatric referrals for medical termination of pregnancy. Indian J Psychiatry 1979;21:149-52. 22. Thara R, Ramachandran V, Mohammed Hassan PP. Psychological aspects of infertility. Indian J Psychiatry 1986;28:329-34. 23. Subramaniam D, Subramaniam SK, Charles SX, Verghese A. Psychiatric aspects of hysterectomy. Indian J Psychiatry 1982;24:75-9. 24. Mahapatro F, Parkat SR. A comparative study of coping skills and body image: mastectomized vs. lumpectomized patients with breast carcinoma. Indian J Psychiatry 2005;47:198-204.
Rakesh K. Chadda Mamta Sood Department of Psychiatry All India Institute of Medical Sciences New Delhi - 110 029, Ind Kumar and Yeragani: Psychosomatic medicine in Indian context 36 Psyche and soma: New insights into the connection
Rahul Kumar, Vikram K. Yeragani
ABSTRACT
The interaction of Psyche and Soma are well known and this interaction happens through a complex network of feedback, medication, and modulation among the central and autonomic nervous systems, the endocrine system, the immune system, and the stress system. These systems, which were previously considered pristinely independent, in fact, interact at myriad levels. Psychoneuroimmunology (PNI) is an emerging discipline that focuses on various interactions among these body systems and provides the underpinnings of a scientific explanation for what is commonly referred to as the mind-body connection. This article reviews the relevant literature with an emphasis on Indian research.
Key words: Mind-body connection, psyche and soma, Psychoneuroimmunology
INTRODUCTION
Integral physiology has to do with the synthesis of conventional physiology and how our individual psyches (i.e., mind, emotions, and spirituality) interact with the world around us, to induce positive or detrimental changes in our bodies. In a broader sense, the concept applies to the health of society as a whole. In the past two decades, biomedical research has changed our understanding of body systems. It has now come to light that there is a complex network of feedback, mediation, and modulation among the central and autonomic nervous systems, the endocrine system, the immune system, and the stress system. These systems, which were previously considered pristinely independent, in fact, interact at myriad levels. Psychoneuroimmunology (PNI) is an emerging discipline that focuses on various interactions among these body systems and provides the underpinnings of a scientific explanation for what is commonly referred to as the mind-body connection. One should not construe here that all the phenomena are finally mediated only through immune mechanisms.
EMERGENCE OF PNI
In 1964, George Freeman Solomon wrote "Emotions, immunity, and disease: A speculative theoretical integration." In this article, Solomon first used the term 'psychoimmunology' and introduced the concept of a medical link between our emotions and immune systems.[1] In 1975, Ader expanded on Solomon's work and coined the term 'PNI'. During that same year, Ader and his colleagues published the startling results of their research on the conditioned immune response in a rat population.[2] The rats in the experimental group were injected with cyclophosphamide (an immunosuppressive agent), while simultaneously being given drinking water flavored with saccharin. The rats were later given only the saccharin-flavored water but no cyclophosphamide. To the researchers' surprise, the rats continued to evidence immunosuppression. This was the first documented example of Pavlovian conditioning of the immune response. In Ader's groundbreaking research, he used a pharmaceutical agent to induce the conditioned immune response. Subsequent studies have expanded on the theory to include investigations of conditioning stimuli that are neither physical nor chemical, but are instead cognitive (e.g, perceptions, thoughts, or emotional states). What has been discovered is that these cognitive stimuli can just as easily mediate changes in the immune system. Two noteworthy examples often quoted in the context of PNI are mentioned; one is that lymphocyte activity in men diminishes immediately after the death of a spouse from breast cancer,[3] and second, a study of 75 medical students showed a significant reduction in natural killer- cell activity during the final examinations as compared to the previous month.[4]
Twenty years later, Lancet published a study by Ader and Cohen that concludes with the following statement: "The association between stressful life experiences and changes in immune function do not establish a causal link between stress, immune function, and disease. This chain of events has not been definitively established".[5] Thus, the unifying link remained elusive for a large part of the late twentieth century. Only recently have major breakthroughs occurred that have revolutionized our understanding of PNI. In this article, we will make an attempt to demonstrate the integration among body systems and also the causal link can now be established between these systems based on the available knowledge. CONDITIONED IMMUNE RESPONSE
The key phenomenon that is the basis for the discipline of PNI is the so called 'Conditioned Immune Response'. Research elucidating the interactions between the nervous and immune systems began with studies on conditioned responses of the immune system. As mentioned earlier, in 1975, Robert Ader and his colleagues published their research on the conditioned immune response in a rat population. Similarly, over a hundred years ago, Sir William Osler, the notable physician from John Hopkins, described a patient having an asthma attack after smelling an artificial rose. Although the effects of such conditioning were experientially familiar to physicians, Ader's experiment was the first scientific proof of Pavlovian conditioning of the immune response. Ader's research opened the way to a plethora of studies that illustrate the conditioning of immune suppression, and to some that define immune enhancement as well. Conditioned immune enhancement, like suppression, has now been illustrated with the use of the same chemical, cyclophosphamide, as well as by a variety of other stimuli, including taste and smell.[6] However, much of the earlier research on conditioning involved studies of immune suppression. Many of these studies showed that an aversive stimulus can induce glucocorticoid elevation and immune suppression. It is clear that the hypothalamic-pituitary-adrenal (HPA) axis is a predominant pathway for neuromodulation of the immune system. Ader's work also revealed that antibodies can increase by simply using an antigen as the unconditioned stimulus, postulating that it is the interaction between the immune and neuroendocrine systems that mediates the conditioned response.[7] All of this research suggests that behavior itself is the regulator of immune function.[8]
In this context, we are not ignoring the effect of genetic inheritance, but given that the genes contribute to a particular extent, it is the individual's environment that may decide the final manifestation of an illness. As we mentioned the HPA axis, it is noteworthy to give credit to all the modern work linking the paraventricular nucleus to the production of the corticotrophin- releasing hormone (CRH), which eventually results in cortisol-mediated stress reactions in the body, which can include several different illnesses including cardiovascular (CV) illnesses and sudden death. Our previous and current studies have been examining how anxiety and depression may finally affect the cardiovascular system, leading to an increase in mortality and morbidity. Recent studies have again shown a link between glutamate receptors and some of these mechanisms.
THE CONNECTING LINK
Many neurotransmitters and their receptors, previously thought to be located only in the brain, have been found in the immune system.[8] Conversely, accumulated research shows that any immune function can occur in the brain. When the central nervous system (CNS) receives cognitive stimuli that are relevant to the immune system, it conveys that information by hormonal pathways to receptors on immune cells, causing immunological changes. For example, g-aminobutyric acid (GABA) receptors (GABA being the primary inhibitory neurotransmitter) and benzodiazepine receptors (benzodiazepines being powerful anti-anxiety molecules), typically thought of as being housed in the brain, have been discovered on immune cells and actually modulate the actions of the immune system.[9] This is the physical basis for the mind's impact on the development of disease — a primary example of the mind-body connection.
The nervous system communicates with the immune system via sympathetic fibers coming from and going to the brain. The fibers innervate the primary (i.e, bone-marrow, thymus) and secondary (i.e, spleen, lymph nodes) immune organs including the noradrenergic, cholinergic, and peptidergic nerve fibers.[10] Neurotransmitters must be typically activated by the immune system before passing on their message. Therefore, how does the brain receive and respond to chemical and electrical information from the immune system?
The CNS is capable of modulating the immune system from within the CNS itself (e.g, the microglia have phagocytic functions in the brain). However, modulation predominantly occurs via peripheral immune stimuli affecting the autonomic nervous system (ANS). The information received involves messages with regard to the general type and level of intensity of the intruder, and not information about the specific antigen. In other words, the immune system alone detects an antigen, virus, or bacteria. It then lets the central and peripheral nervous systems in on the news, by way of its own mediators as well as via neuroendocrine mediators. The immune system's activation of the CNS most likely involves the older brain structures, such as the limbic system, and follows discrete neuronal pathways.[11] Interestingly, the immune stimulus (e.g., virus, bacteria, etc.) must reach an, as yet, undetermined but apparent threshold before it is capable of activating the CNS. The CNS can then generate the neuroendocrine peripheral effects. There is, in fact, an interactional and functional relationship between the two systems. For example, when secreted from the sympathetic nerves, epinephrine and norepinephrine generally suppress the immune system, but both have distinct immune enhancing effects in the CNS, potentiated by the immune system's own cytokines, interleukin (IL)-1 and -2.[12] Based on these findings, researchers have designated the immune system a sensory organ for its ability to obtain, process, and then dispatch information to the CNS. One of the greatest examples of the interdependency of the nervous and immune systems came out of the pioneering work that began in the late 1970s, which was performed by Hugo Besedovsky and his colleagues in Germany. They determined that the neuronal firing rates increased in the hypothalamus during the peak antibody response to an immunization, with a corresponding decrease in norepinephrine content of the hypothalamus. Norepinephrine also showed a time-dependent decrease in the spleens of mice following immunization, as well as after an antigen challenge.[13-16] Ten years later, a pattern of increased firing rate corresponding to antibody production was ascertained by another investigator as well.[17] Any alteration in neuroendocrine factors, whether local or systemic, can markedly alter the immune activity. Given the mobile nature of immune cells, messages can reach the immune system through nerves in the vicinity of the target immune cells or via circulation (i.e., local or systemic influences). The first evidence that immune/brain communication causes a peripheral response was the observation that glucocorticoid levels increase when the HPA axis is activated. This systemic change results in immune system adjustments. Likewise, local synthesis and secretion of neuropeptides by immune cells are important for subtler adjustments in the maintenance of immune homeostasis. Research has eventually focused on the precise modulating activities of the neuropeptides as they affect the immune cell function of the immune cells on the neuroendocrine tissue and organs. One must bear in mind that the body systems are sharing receptors for multiple possible combinations of immune, endocrine, stress, and/or nervous system factors that can be elaborated either within or between one another. Cytokines are the immune system's own mediators and are capable of modulating the immune system in a localized manner. For example, IL-1 stimulates itself as well as the tumor necrosis factor (TNF), IL-2, and IL-6, which results in immune modulation.[18] In addition, cytokines are the principal mediators of communication between the immune and neuroendocrine systems, which also result in immune system modulation, particularly with regard to inflammation and infection. The immune system has receptors for foreign stimuli, such as antigen, virus, or bacteria, which, as mentioned, the CNS is incapable of recognizing on its own. However, the immune system can communicate the presence of such stimuli through cytokine immunological messengers.[19]
On recognition of the cytokine by the CNS, the information is converted to neuroendocrine signals, resulting in chemical messages being sent back to the immune system, with ensuing physiological changes. By and large, the cytokines (and their receptors) that are found in the nervous system are localized to the brain. Although most research has been performed on rodents, TNF and Interferon g(INFg) have been found in human brain tissue and IL-1 in the tissues of human hypothalamus, thyroid, and ovary as well. A detailed analysis shows that different cytokines have discrete portions of the brain that they are capable of stimulating: Dopamine in the striatum, prefrontal cortex, and hippocampus; serotonin predominantly in the hippocampus; and tryptophan accumulating in a more diffuse fashion in the CNS.[20,21] The effect of having cytokines localized in the brain was that they were capable of influencing neuroendocrine production. Among the first cytokines found to have hormonal function were INF, which increased glucocorticoid production, and IL-1, which increased the hypothalamic secretion of the corticotropin-releasing hormone (CRH).
However, now we know that cytokines are responsible for numerous neuroendocrine alterations. The activated immune system sends both humoral and neural messages to the brain that there is some type of intruder (antigen, virus, or bacteria) present in the body. On recognition of the cytokine by the CNS, the brain converts the information to neuroendocrine signals, resulting in chemical messages being sent back to the immune system. The CNS response to the cytokine message either affects distinct neuroendocrine functions that are under the control of the CNS (e.g., stimulating the HPA axis), or it promotes the behavioral properties of peripheral cytokines (e.g., fever). The hypothalamus, hippocampus, and the pituitary of the CNS, as well as, the sympathetic nerve terminals of the peripheral nervous system are the primary sites at which communication occurs.[22] Another route for cytokine modulation in the CNS is via the immune cells themselves. Activated immune cells are capable of permeating the blood-brain barrier and secreting cytokine mediators. This interaction is distinct from the cytokines independently traveling to the CNS. Studies show that these brain-born cytokines can influence peripheral neuroendocrine functions and influence behavioral effects, particularly those associated with the hypothalamus and hippocampus. These actions probably help maintain homeostasis, by modulating the interaction of the systems during antigen challenge. Moreover, a fascinating research shows that IL-1, IL-2, IL-6, TNFa, and INFg, all cause pituitary-like hormones to be secreted by immune cells in a localized autocrine-and paracrine-type manner. This news is astounding, and the implications for the modulation and integration of systems are profound. These lymphocyte-derived, pituitary-like hormones actually modulate subtle adjustments in pituitary hormone secretions. For example, IL-1 regulates anterior pituitary cell growth, while IL-2 and IL-6 inhibit normal growth yet encourage tumor growth.[23] As for the other aspects of immune- neuroendocrine bidirectional communication, we see that the cytokines play an enormously important role in system homeostasis during immune challenges.
Integration: The potential for harmony
Chemical and electrical transmitters, once thought to have limited and discrete functions, are found to have a significant impact on one another, often interchanging functional roles. Although studies bringing to light specifics such as the fact that lymphocytes have receptors and secrete neuropeptides are of enormous significance to medical science, and the intricacy in systems interaction that will be revealed in the coming decade will be far more astounding. Now that scientists have discovered the functional modulators that have the most dynamic influence on the body, increasingly subtler ones are being detected. The HPA axis is connected to a memory system for stress and trauma. We can now begin to speculate that the immune system also has a memory beyond that which is specific to the antigen memory. The same sites (e.g., the hippocampus and hypothalamus) that are recognized as crucial for memory functions of stress are also fundamentally important in the immune-neuroendocrine bidirectional communication pathway. Both these sites are important transfer stations for cytokines — the all-important interceding messengers. The ubiquitous and intricate array of electrical and chemical routes of communication that are already known to make up immune response are a compelling indication that there could be a memory for the emotional or behavioral components of an illness. What are some of the practical implications of understanding that our bodies are integrated networks? We know that illness and psychosocial factors, such as stress, bereavement, or divorce, can change or deplete immune performance and alter neuroendocrine function. The impact of these events on one's health is understood more fully from the perspective of systems integration. Our bodies have the capacity to function with separate, yet fully interactive parts maintaining homeostasis. There is a harmony, whose sum is greater than the parts — in other words, there is integral physiology.
Mind body interactions and their influence on the pathophysiology of disease
We toil with the understanding that cells of the immune system have receptors for neurotransmitters, neuropeptides, and hormones, and we embrace the notion that primary and secondary lymphoid tissues are innervated by the sympathetic nervous system. We have a solid working knowledge of how stressors activate the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, and we also have an appreciable grasp of how products of these systems affect molecular and cellular changes in the immune system.
As far back as the early twentieth century, investigators who were undertaking hypothesis-driven research in psycho somatic medicine demonstrated the importance of mind-body interactions in the pathophysiology of disease. In the 1930s Walter Cannon was one of the first to note that fear and stress contributed to the development of physical symptoms akin to heart disease.[24] Subsequently, it was noted that multiple psychological risk factors were present in a large population of patients with heart disease. These could be chronic personality traits, such as hostility; there could be episodic factors, which could include depression and exhaustion; or risk factors that could manifest in the form of something like anger, which was classified as an acute psychological trigger. As the years passed, since Cannon's observations, the results of an increasing number of studies suggested that the immune system played an important role in the relationship between these psychological risk factors and future coronary syndromes.
Psychological factors have also been implicated in the onset and exacerbation of various skin disorders. Dysregulation of the hypothalamic-pituitary- adrenal axis and sympathetic-adrenomedullary system are proposed to aggravate the allergic inflammatory process in atopic dermatitis.[25]
While the influence of stress on the development of cardiovascular and inflammatory diseases was among the first areas in psychoneuroimmunology to receive attention, the field broadened significantly, as the role of inflammation in numerous central and peripheral processes became evident. The adipose tissue is now recognized as a dynamic organ with important roles in modulating satiety, reproduction, immunity, and metabolism. More importantly, it has been reported that the obese exhibit increased markers of inflammation including macrophage infiltration. Studies on the relationship between inflammation and obesity may provide information on the pathologies associated with obesity.[26] PNI also has a pivotal role in host defenses. Pathogen recognition has been a major focus of immunological research for the past decade. Studies on innate resistance and the mechanism by which a mammal initially recognizes a viral or bacterial challenge have provided an insight into basic host resistance. The long-held dogma of 'self versus non-self' discrimination as the capstone of immune response has been modified to include the concept of 'danger signals'.[27]
Danger signals are elicited in damaged tissues in response to insult/injury, and they provide information through primitive receptor-ligand interactions, as part of an innate resistance. Exposure to mental or physical stressors stimulates a cascade of behavioral and physiological responses that are directed at improving an organism's chance of survival. At the cellular level, the induction of heat shock proteins — specifically heat-shock protein 72 (Hsp72) — may be a previously unrecognized feature of an acute stress response. Hsp72 may function as an endogenous 'danger signal,' leading to the facilitation of immune responses during times of acute stress.[28] Various infectious diseases commonly befall the average person, and diseases caused by bacteria and viruses continue to be a significant cause of morbidity and mortality worldwide. Psychoneuroimmune interactions are also critical factors that influence microbial pathogenesis and individual susceptibility to infection. A large body of research has linked psychosocial factors to variations in HIV disease progression. However, the biological processes mediating those effects remain poorly understood. The biological signaling pathways that convey the effects of the psychosocial factors to the cellular and molecular processes involved in HIV pathogenesis have been better understood in recent years.[29] A latent viral infection (herpes simplex virus, HSV) that is associated with stress-induced reactivation has also helped the scientists to study the PNI aspects of stress inducing such a phenomenon.[30]
Stress-induced neuroendocrine interactions are also known to influence the immune system during a viral infection, which may possibly lead to an autoimmune disease. A Theiler's virus infection of the central nervous system model is being used for the study of multiple sclerosis (MS), and the basic pathology of the disease and the present evidence do support the role of viral infection in the etiology of MS. The role of stress on the development of MS has also been proved, paying particular attention to the anti-viral immune responses in the development of the disease.[31] Based on the existing body of evidence, an attractive model of the Psycho-Neuro-Immune axis has been proposed and is presented here.
The Indian scenario
Ultimately all the hypotheses should be proven in the systematic, basic, and clinical research, not only to identify the risk and mechanisms that mediate an illness, but also to know how various treatments can be beneficial. For example, all our ongoing work on the risk factors of cardiac mortality and morbidity, associated with anxiety and depression, is a miniature attempt to understand one aspect of an elaborate phenomenon.[32] Our recent work on how physical exercise may affect the repolarization lability in ventricular myocardium is one such example.[33] In this context some other works on the effects of the brain on the mediation of cardiac repolarization is exciting, as it links the medial prefrontal cortex, the QT interval. Likewise, it will be very fruitful to understand the mechanisms of many modalities of treatments, where the psychological, spiritual, and pharmacological means may yield valuable information in future, delineating the sympathovagal balance in the system.
In the Indian context, an association between the psyche and well being has been referred to in the ancient Epics such as the Ramayana, Mahabharata, and the Bhagwat Geeta. In the modern era, the first reference to this topic was published in Psychosomatic Medicine in 1946.[34] The author reviewed the charts of 1266 consecutive patients treated by him in a year on a General Medical Section of an Army hospital in Assam, India. Nine hundred and twenty-eight patients (73.3 percent) had organic, somatic diseases; 104 (8.2 percent) had full-blown psychoneurosis; 234 (18.5 percent) had a combination of the two: Psychosomatic illnesses. In other words, one out of every four general medical patients had a large emotional component to his illness. Of late, the impact of Psychoneuroimmunology has also been addressed in relation to tuberculosis[35] and the field of Medical Oncology. [36] However, an original research on the topic is lacking and further studies are needed in the Indian perspective, as the dynamics and family support structure is different in India when compared to the West.
The authors have carried out a study on the Intensive Care Patients, where the outcome was compared to the coping skills of the patients (unpublished data). The coping skills were assessed using the Bell's inventory and the style- questionnaire and were compared with the final outcome. The cohort of patients studied were patients with sepsis. The assessment of neuroimmune functions was done by estimating the Tumor Necrosis Factor a, Interleukin 1, and Interleukin 6 levels. A direct correlation was noted between optimism and good coping skills to a favorable outcome. It was also noted that the immune response was more streamlined in individuals having good coping skills.
In an interesting and thought provoking editorial, Sathyanarayana et al. have addressed the issue of the control of the mind over body.[37] They mention "The biochemistry of our body stems from our awareness.[38] Belief- reinforced awareness becomes our biochemistry. Each and every tiny cell in our body is perfectly and absolutely aware of our thoughts, feelings, and of course, our beliefs. There is a beautiful saying 'Nobody grows old. When people stop growing, they become old'. If you believe you are fragile, the biochemistry of your body unquestionably obeys and manifests it. If you believe you are tough (irrespective of your weight and bone density!), your body undeniably mirrors it. When you believe you are depressed (more precisely, when you become consciously aware of your 'Being depressed'), you stamp the raw data received through your sense organs, with a judgment — that is your personal view — and physically become the 'interpretation' as you internalize it. A classic example is 'Psychosocial dwarfism', wherein, children who feel and believe that they are unloved, translate the perceived lack of love into depleted levels of the growth hormone, in contrast to the strongly held view that the growth hormone is released according to a preprogrammed schedule coded into the individual's genes!"
CONCLUSION
It is not at all an exaggeration if we state that there is much more to be learnt Figure 1: Neuro-anatomical/physiological basis of psychosomatic responses in spite of all the above advances. Hopefully, we may identify the exact neuronal pathways of the psychological effects and their mediation on the soma. However, we already see a lot of fruits resulting from this.
REFERENCES
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Reichlin S. Neuroendocrine-immune interactions. N Engl J Med 1993;329:1246-53. 9. Song C, Leonard BE. Fundamentals of Psychoneuroimmunology. Chichester, U.K: John Wiley and Sons, 2000. 10. Ackerman KD, Bellinger DL, Felten SY, Felten DL. Ontogeny and senescence of noradrenergic innervation of the rodent thymus and spleen. In: Psychoneuroimmunology. 2nd ed. In: Ader R, Felten DL, Cohen N, editors. New York: Academic Press; 1991. p. 71- 125. 11. Besedovsky HO, del Rey A. Physiological implications of the immune-neuro-endocrine network. In: Psychoneuroimmunology. 2nd ed. In: Ader R, Felten DL, Cohen N, editors. New York: Academic Press; 1991. p. 589-608. 12. Zalcman S, Green-Johnson JM, Murray L, Nance DM, Dyck D, Anisman H, et al. Cytokine- specific central monoamine alterations induced by interleukin- 1, -2, and -6. Brain Res 1994;643:40-9. 13. Besedovsky HO, Sorkin E. Network of immune-neuroendocrine interactions. Clin Exp Immunol 1977;27:1-12. 14. Besedovsky HO, del Rey A, Sorkin E. Antigenic competition between horse and sheep red blood cells as a hormone-dependent phenomenon. Clin Exp Immunol 1979a;37:106-13. 15. Besedovsky HO, del Rey A, Sorkin E. What do the immune system and the brain know about each other? Immunol Today 1983a;4:342-6. 16. Besedovsky HO, del Rey A, Sorkin E, Lotz W, Schwulera U. Lymphoid cells produce an immunoregulatory glucocorticoid increasing factor (GIF) acting through the pituitary gland. Clin Exp Immunol 1985;59:622-8. 17. Saphier D, Abramsky O, Mor G, Ovadia H. Multiunit electrical activity in conscious rats during an immune response. Brain Behav Immunity 1987;1:40-51. 18. Dinarello CA, Ikejima T, Warner SJ, Orencole SF, Lonnemann G, Cannon JG, et al. Interleukin 1 induces interleukin 1: I, Induction of circulating interleukin 1 in rabbits in vivo and in human mononuclear cells in vitro. J Immunol 1987;139:1902-10. 19. Bulloch K, Pomerantz W. Autonomic nervous system in nervation of thymic-related lymphoid tissue in wild type and nude mice. J Comp Neurol 1984;228:57-68. 20. Besedovsky HO, del Rey A. Immune-neuro-endocrine interactions: Facts and hypotheses. Endocrine Rev 1996;17:64-102. 21. Besedovsky HO, del Rey A. Cytokines as mediators of central and peripheral immune- neuroendocrine interactions. In: Psychoneuroimmunology. 3rd ed. In: Ader R, Felten DL, Cohen N, editors. New York: Academic Press; 2001. p. 1-17. 22. Scarborough DE. Cytokine modulation of pituitary hormone secretion. Ann N Y Acad Sci 1990;594:169-87. 23. Arzt E, Páez Pereda M, Costas M, Sauer J, Renner U, Holsboer F, et al. Cytokine expression and molecular mechanisms of their auto/paracrine regulation of anterior pituitary function and growth. Ann N Y Acad Sci 1998;840:525-31. 24. Cannon WB. The wisdom of the body. 2nd ed. New York: WW Norton and Company; 1939. 25. Picardi A, Abeni D. Stressful life events and skin diseases: Disentangling evidence from myth. Psychother Psychosom 2001;70:118-36. 26. Lindsay RS, Wake DJ, Nair S, Bunt J, Livingstone DE, Permana PA, et al. Subcutaneous adipose 11 betahydroxysteroid dehydrogenase type 1 activity and messenger ribonucleic acid levels are associated with adiposity and insulinemia in Pima Indians and Caucasians. J Clin Endocrinol Metab 2003;88:2738-44. 27. Matzinger P. Tolerance, danger, and the extended family. Annu Rev Immunol 1994;12:991- 1045. 28. Gao B, Tsan MF. Endotoxin contamination in recombinant human heat shock protein 70 (Hsp70) preparation is responsible for the induction of tumor necrosis factor alpha release by murine macrophages. J Biol Chem 2003a;278:174-9. 29. Antoni MH, Cruess DG, Klimas N, Carrico AW, Maher K, Cruess S, et al. Increases in a marker of immune system reconstitution are predated by decreases in 24-h urinary cortisol output and depressed mood during a 10-week stress management intervention in symptomatic HIV-infected men. J Psychosom Res 2005;58:3-13. 30. Pereira DB, Antoni MH, Danielson A, Simon T, Efantis-Potter J, Carver CS, et al. Stress as a predictor of symptomatic genital herpes virus recurrence in women with human immunodeficiency virus. J Psychosom Res 2003;54:237-44. 31. Sospedra M, Martin R. Immunology of multiple sclerosis. Annu Rev Immunol 2005;23:683- 747. 32. Kumar R, Ramachandraiah CT, Chokka P, Yeragani VK. Mean and variability of QT interval: Relevance to psychiatric illness and psychotropic medication. Indian J Psychaitry 2009;5:6- 8. 33. Ksocchke M, Botteger MK, Scultz S, Berger S, Terhaar J, Voss A, et al. Autonomy of autonomic dysfunction in major depression. Psychosom Med 2009;71:852-60. 34. Hamburger WW Jr. Psychosomatic medicine in an army hospital in India. Psychosom Med 1946;9:124-30. 35. Lalit K, Nagpaul DR. Psychiatric disorders and illness perception in tuberculosis. Indian J Tuberculosis 2006;48:55-7. 36. Nandini V. Perspective on psychoneuroimmunology in oncology. Indian J Palliat Care 2006;12:29-33. 37. Sathyanarayana Rao TS, Asha MR, Jagannatha Rao KS, Vasudevaraju P. The biochemistry of belief. Indian J Psychiatry 2009;51:239-41. 38. Chopra D. Ageless body, timeless mind: The quantum alternative to growing old. Hormony Publishers; 1994. ISBN -10: 0517882124.
Rahul Kumar M.S. Ramaiah Medical College and Hospital, Bangalore
Vikram K. Yeragani Departments of Psychiatry, University of Alberta, Edmonton, Alberta, Canada; Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA; Biotechnology, Aacharya Nagarjuna University, AP, India Kallivayalil and Punnoose: Understanding and managing somatoform disorders 37 Understanding and managing somatoform disorders: Making sense of non- sense
Roy Abraham Kallivayalil, Varghese P. Punnoose
ABSTRACT
Somatization is a clinical and public health problem as it can lead to social dysfunction, occupational difficulties and increased healthcare use. Hence understanding somatoform disorders is of paramount importance, especially so in developing countries like India. This paper discusses the history and evolution of the concept of somatization and somatoform disorders, etiological considerations, classification, assessment, diagnosis and clinical management. Research from India, controversies and criticisms and future perspectives are mentioned. A new model to understand functional somatic symptoms, in Indian setting is also proposed.
Key words: Somatoform disorders, Medically unexplained somatic symptoms, Management, Positive explanation
"I am more sick than my doctors think" –Alfred Nobel INTRODUCTION
Somatization is a poorly understood "blind spot" of Medicine.[1] Somatoform disorders remain neglected despite functional impairment and economic burden. Conceptual and clinical questions exist about the validity and utility of the concepts. New paradigms might lead to more effective management.[2]
In somatoform disorders, physical symptoms suggest a physical disorder, but there are no demonstrable organic findings and there is strong evidence for link to psychological factors or conflicts. The term is from Greek, "soma" for body. In the middle ages, these disorders were believed to be spiritual disorder of evil and demonic possession. In the 17th century, Sydenham said, "hysteria could simulate any medical disease". In the 19th century, it was Briquet who made the first systematic description of hysteria with 430 cases. Briquet, Reynold, Charcoat all believed that hysteria is a CNS disease. 'Studies on Hysteria' (1893-95) by Breur and Freud gave new insights. Freud explained the syndrome of hysteria as "conversion of emotional distress into physical symptoms". Later, hysteria became less popular as a diagnosis. The term 'somatization' was introduced by Stekl to denote "the expression of emotional distress as bodily symptoms". Hysteria has pejorative associations. It might represent misdiagnosis of organic disorders.[3] It was the St Louis group Perley and Guze[4] who described the Briquet's syndrome as "chronic multiple somatic symptoms, with no identifiable organic cause". They had regarded this as a form of hysteria.
A similar syndrome was described as somatization disorder in DSM III. The term somatoform disorders was introduced in DSM III for "a group of disorders characterized by physical symptoms, not explained by organic factors". This new category included traditional psychiatric disorders like hysteria and hypochondriasis, together with newly proposed categories like somatization disorder. Somatoform disorders and dissociative disorders were introduced in DSM III "to rationalize what has been previously regarded as neurosis". These groupings were tentative, lacking substantial evidence base and unsatisfactory.
According to DSM IV, in somatoform disorders the common feature is "presence of physical symptoms which suggest a general medical condition and are not fully explained by general medical condition, substance use or another mental disorder". This disorder also produces clinically significant distress or impairment in social, occupational or other important areas of functioning. Symptoms are not intentional, contrasting it with factitious disorder or malingering. Conversion disorder is placed in the somatoform section to consider neurological or medical conditions in differential diagnosis. However, the evidence base for diagnosis and treatment remains sub-optimal.
Conceptualizing somatoform disorders
Somatization can be conceptualized as a process which appears fundamentally as a way of responding to stress. Another concept is somato sensory amplification, where somatic symptoms are experienced as intense, noxious or disturbing.[5] It has three elements i) hypervigilance (to bodily sensations) ii) selecting out some sensations (which are weak) and iii) intensification by cognition and affect, making them more alarming. Somatization is a clinical and pubic health problem as it can lead to social dysfunction, occupational difficulties and increased health care use. Somatization can also be viewed as masked psychiatric disorder (eg: Depression or Anxiety) or amplified personal perceptual style (due to personality trait or abnormal neuro-psychololgical information processing) or as seeking care for emotional distress or as a response to health care incentives (iatrogenic somatization).
Etiological considerations include patho-physiological mechanisms, genetic and developmental factors, cognitive theories, personality characteristics, psychodynamic factors, sexual and physical abuse, socio-cultural factors, gender and iatrogenesis. Patho-physiological mechanisms can be physiological, psychological and inter-personal. Postulated physiological mechanisms are autonomic arousal, muscle tension, hyperventilation, vascular changes, and cerebral information processing and sleep disturbance. Among psychological mechanisms, perceptual factors, beliefs, mood and personality factors are important. Significant inter-personal mechanisms include re-inforcing actions of relatives and friends, health care system and disability benefits.
Classification: In DSM IV, Somatoform disorders include somatization disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, undifferentiated and somatoform disorder NOS In ICD 10, body dysmorphic disorder is included under hypochondriasis and also there are categories for somatoform autonomic dysfunction and other neurotic disorders like neurasthenia. The present classification of somatoform disorders has been criticized by many. Important criticisms are i) mixture of principles for diagnostic criteria (eg: etiology, symptom count and response to treatment) ii) non-specific categories iii) categories are broad and vague iv) possibility to use them for nearly all persistent medically unexplained symptoms and v) leads to large discrepancies in prevalence.
Somatization disorder is chararacterized by multiple somatic symptoms of long duration beginning before the age of 30 years. This was called Briquet's syndrome (1962) earlier. A similar syndrome was named as somatization disorder in DSM III (1980). The diagnostic criteria were highly restrictive in DSM IIIR.[6] DSM IV[7] made the criteria less restrictive.
Understanding functional somatic symptoms in Indian setting - A new model
In modern medicine, clinical disciplines traditionally consider only those symptoms which are associated with a physical sign or a laboratory finding as significant. Even when these are absent, a pathophysiology, which is known or at least presumed, may also lend some respectability for the symptoms. For example, complaints like weakness of limbs when associated with changes in deep tendon reflexes or chest pain when ischemic changes in ECG are demonstrated or headache descriptions suggestive of vascular origin or fatigue when investigated shows high TSH values are readily accepted as genuine symptoms. In training undergraduates and post graduates in clinical sciences, only those cases with demonstrable findings and laboratory evidences are thought to be worthy of any serious diagnostic considerations. Hence it is not surprising that they are never taken up for a bedside discussion or a case conference. But in actual clinical settings, either in general practices or in specialty settings, the situation is quite different. A significantly high proportion of patients present with complaints which are not justified by the presence of a corresponding physical sign or a laboratory finding.
As far as the management of these patients is concerned, initially investigations are suggested with enthusiasm and curiosity from the part of the physician to unearth an elusive mysterious diagnosis. Many young doctors are carried away by the medical fairy tales of great clinicians of yesteryears (either intuitively or by ordering for an extraordinary investigation) making rare diagnoses, which has eluded the less diligent eyes of the lesser mortals! But as the patient continues to present with new set of symptoms in every visit or persist with the same complaints and the investigations continue not to reveal anything significant, the initial interest and enthusiasm gives way to frustration and helplessness. This can lead on to unpleasantness and loss of trust in the doctor-patient relationship. The patient who initially had complied to every suggestion for a new investigation or procedure with a hope of getting a diagnosis may start accusing the doctor of forcing unnecessary investigations (with ulterior motives)!
The physician on the other hand may try to believe and explain the symptoms as resulting from vague constructs like allergy, wear and tear due to ageing, psychosomatic, perimenopausal symptoms etc. He may have ambivalent feelings about the possibility of missing a real problem. A physician is also likely to experience guilt over his inability to help the patient, over his incompetency as a clinician, and over the expenses which the patient had to incur. As a reaction formation to these feelings, she may start seeing the patient as a malingerer who is eating up her valuable time and using up the limited medical resources unnecessarily. On the patient's side also the emotions can run high. He feels betrayed and not cared by his doctor. On the relentless pursuit of finding a meaning to his symptoms he may start believing in equally imprecise constructs like low blood pressure, high ESR, eosinophilia, which may be inadvertently and covertly agreed by the physician who is equally, if not more, at a loss to explain the symptoms!
Unfortunately, in India, undergraduate and post graduate medical and psychiatric training is grossly inadequate to understand and effectively deal with these cases which are considered to be functional! This article is written in the background of clinical experience of the authors in a consultation - liaison setting of a general hospital psychiatry unit. The reasons for medically unexplained physical symptoms remaining one of the areas least explored despite their common occurrence may include the following.
1. Traditionally these conditions are not considered part of core psychiatry. The nosology and classification of these conditions are confusing and controversial. 2. Psychiatrists who are trained in mental hospitals are least exposed and not having adequate expertise in this area. 3. Reluctance from the part of patients to seek psychiatric help. 4. Difficulties encountered by general practitioners and specialists in making a referral for psychiatric help.
Authors from the West have proposed many models in understanding functional somatic symptoms. For example, Linda Gask[8] described a practical model for the detection, acknowledgement and management of these conditions which can be easily learned and used in primary care. The three stage model emphasizes the importance of shared care between the psychiatrist and the primary health care team. These models are either directed to psychiatrists or primary care physicians.[9,10,11,12] Incorporating the research from the developing world, WHO also has come out with training packages addressing the need of such communities.[13] Each of these models has their own strengths and problems. Every centre need to develop and evolve models suiting their needs and limitations as there cannot be a single ideal universal algorithm which may suit a condition as complex and diverse as functional somatic symptoms.
We propose a model for understanding functional somatic symptoms, which is expected to be friendly to the non- psychiatrist users. The non- psychiatrist medical professional may consider the following possibilities when he is encountering medically unexplained somatic symptoms.
1. Symptoms which are in excessive (disproportionate to) the "real disease" 2. Anxiety disorders and Depressive disorders presenting with physical symptoms 3. No known physical or common mental disorders to account for the somatic symptoms. 4. Acute and dramatic presentation of physical symptoms without a medical cause. 5. Concern and conviction of a disease when none exists. 6. Deliberate feigning of diseases.
Symptoms which are in excessive (disproportionate) to the "real disease"
This constitutes one of the most frequently encountered situations in clinical practice. This pattern of excessive complaining and dissatisfaction may baffle and annoy the physician who expects the patient to show a corresponding improvement directly proportional to the physical signs and lab reports. This may be due to the following factors a) Normal regressive behavior associated with any medical illness b) Propensity of certain temperamental - personality types to perceive symptoms in high intensity c) Autonomic responses associated with anxiety leading to physical symptoms d) Reward-punishment contingencies perpetuating illness behavior
Anxiety/depressive disorders presenting with physical symptoms
The conventional view is that it is the psychological symptoms and not physical symptoms which constitute the legitimate presentation of these emotional disorders. The neurobiological basis of Anxiety disorders and Depressive disorders points to the involvement of dysfunctional serotonergic, nor-adrenergic or dopaminergic neuronal circuits. If the physician realizes that the same dysfunctional circuits can produce "real" physical symptoms and they are thus legitimate manifestation of disorders which are primarily emotional, that will give an explanatory model which will not produce cognitive dissonance to a medically trained mind. Thus he will consider anxiety disorders and depressive disorders higher up in the priority list of differential diagnosis putting them much ahead of rare conditions like acute intermittent porphyria or pheochromocytoma.
No physical or mental disorders to account for the somatic symptoms
When the somatic symptoms cannot be explained based on the above mentioned situations, they become much more difficult to be understood. Even the psychologically minded physicians find it difficult to empathize with this group. Medical professionals not trained in psychiatry may find it very difficult to understand the subtle difference between these disorders and conditions which are of factitious nature. One has to admit that these patients constitute the group which is difficult to tag a diagnosis and manage in the usual way, by virtue of the very nature and chronicity characteristic of these disorders. Naming them as somatoform disorders or sub typing them into somatization disorder or pain disorder may help to differentiate them from malingering or factitious disorders but may not help much in understanding or managing them. But if the physician can understand that these disorders are a result of abnormal processing and perception of signals in the central nervous system, it may help not only them, but also the patients or their worried relatives to make sense out of this baffling presentation.
Acute and dramatic presentation of physical symptoms without a medical cause
A psychiatrist may label them as a conversion disorder or a dissociative disorder when such disorders are presumed to have a causal relationship to a psychological conflict which may be unconscious. When he makes a referral to a psychiatrist, a medical professional is usually not bothered over these subtleties and is worried whether he is missing an organic cause, is concerned about symptom removal, and is often curious about the psychological stressor identified. Very often, experienced physicians have evolved their own method of dealing with "hysterical" cases from their experience and not from any formal psychiatric training. One has to admit that these methods are effective at least for symptom removal. The practical difficulties in referring these patients for a psychiatric consultation often cited by physicians are also very valid in the background of our cultural context.
Concern and conviction of a disease when none exists
For the psychiatrist, this group whose main concern is not the symptoms, but the beliefs about health, disease and diagnosis may be hypochondriasis, a sub type of somatoform disorder. Understanding the relationship between health anxiety and beliefs about diseases and ill health may provide better insight for the physician in empathizing with these patients who are very likely to elicit negative emotional responses from the therapist and other care takers.
Deliberate feigning of diseases
The subtle difference between factitious disorders and malingering does not bother the non-psychiatrist. The fact that these disorders are relatively rare compared to the more common place conditions described above should be imparted to them rather than heading for the hair splitting arguments over factitious versus malingering.
These six situations need not be considered essentially in the exact order given as above. The priority in this article has been assigned depending on the frequency usually encountered in clinical practice in a general hospital setting. We have abided by the clinical dictum that 'uncommon presentations of common conditions are much more common than common presentation of rare conditions' in assigning this priority. The clinician should use his practical wisdom in determining priorities in individual cases.
Assessment and diagnosis of somatoform disorders
Building an alliance with the patient, collaborating with referral source, reviewing the medical records, gathering collateral information from others, performing psychiatric examination and MSE and physical examination are integral to a proper diagnosis.
Clinical management
Adopting 'caring rather than curing as the goal' is useful. Management strategies include i) Re- attribution approach ii) Pychodynamic approach and iii) Directive approach. In re-attribution approach the patient is helped to link his physical symptoms with psychological or stressful factors in his life. This is useful in those patients with insight, in short duration illness and for use in PHCs. In the psychotherapeutic approach, the thrust is in forming a close and trusting relationship with the patient. This modality may be useful in persistent somatization. In directive approach, the patient is treated as though he has a physical problem. Interventions are framed in the medical model. This approach is useful in hostile patients and those who deny the relevance of social or psychological factors.
Principles of management
Are fundamentally same for management of all somatoform disorders. They are: i) Providing a positive explanation for the symptoms, without dismissing them. Symptoms are to be seen as real and the physician has to appear as one who is keen to explore all possibilities for symptom removal ii) Ensuring regular follow- up (and not 'symptom-driven' visits) iii) Treating mood or anxiety disorders iv) Minimizing polypharmacy v) Providing specific therapy (eg: physiotherapy to reduce musculo- skeletal pain) vi) Changing social dynamics that re-inforce the symptoms vii) Emphasizing doctor- patient relationship viii) Recognizing counter-transference ix) Suggestions and reassurance. Explanations are given to empower the patient, emphasizing good prognosis and ensuring active involvement of the patient and x) Specific treatment models like pharmacotherapy, behavior treatments including cognitive therapy and CBT, dynamic psychotherapy, group therapy, marital therapy, family therapy, physical and relaxation therapies. Amalgamating the reviews by O'Dowd (1988), Bass and Murphy,[11] Goldberg et al.,[13] and Bass and Benjamin[10] many principles can be suggested in the management of chronic somatization in primary care.
Research from India: Chandrasekhara R et al. (1964) found, hysterical neurosis as one of the commonest mental disorders in India. Of the 38 women followed up for five years, 63% remained asymptomatic. Raguram R et al.[14] found stigma is positively correlated to depressive symptoms and negatively to somatoform symptoms. Chaturvedi et al.[15] designed a screening test of abnormal illness behavior in patients with somatic symptoms -SIBQ- which was useful for busy centers. Nambi SK et al.[16] found primary care patients believed in the physical nature of the complaint and in its serious nature. Hence understanding patient's perspective becomes important. Patel V (2005) found stress as common attribution for vaginal discharge. In such patients there were high scores for somatoform disorders and CMD. Malhotra S et al.[17,18] found, in children and adolescents, somatoform disorders and dissociative disorders were closely linked. Age at presentation and intelligence were significantly higher in somatoform disorders. Trivedi JK et al.[18] found somatization patients may have substantial cognitive deficits, especially in executive functions, attention, concentration and memory. This might lead to poor psycho social functioning. Paralikar VP et al.[19] studied biomedical markers and psychiatric morbidity in neurasthenia spectrum disorders and found anxiety and somatoform disorders were more frequent than depressive disorders
Controversies and Criticisms: Some of the important ones about Somatoform Disorders are i) Dualistic explanation sees mind and body exclusively ii) There is dichotomy into psychogenic and somatogenic categories iii) 'Psychogenic in origin' is implied in the terminology iv) Many cultures including Indian, do not share the western concept of mind body dualism v) There is lack of clear operational definitions and vi) This seems to be an artificial grouping of conditions and the basis may be 'psychiatric disorders presenting in Medicine'. There is no doubt, some of these criticisms are valid and it should focus our attention on improving the classification in future.
Future Perspectives: Hypochondriasis and somatization are so enduring and is it more appropriate to classify them as personality disorders. Also, physical and psychological factors contribute to the illness. Hence the dualistic view is likely to be rejected in future. Also there is increasing acceptance that pain cannot be meaningfully classified as either somatogenic or psychogenic.[20,21] And co-morbidity of somatoform disorders with depression and anxiety need to be important considerations for the future.
CONCLUSION
Managing FuSS (Functional Somatic Symptoms) patients is a challenging task for any physician. First and foremost, it is crucial to accept the real nature of the symptoms, with the exception of factitious disorders. Giving an explanatory model for the patient for his symptoms is very important. A patient with medically unexplained somatic symptoms is often at a loss to understand the why and how of his symptoms. Quite often, he is given vague and contradictory explanations which may not be suiting his belief systems and thinking. Prescriptions of psychotropic medicines given without a convincing explanation are very likely to be perceived by the patient as dishonest.
A model which focuses on dysfunctional neurotransmission and brain circuits which are influenced by external stressors and internal conflicts leading on to symptoms may be appropriate in the first three situations. Abnormal signal transmission and processing in the nervous system may also be brought in as legitimate explanations for these conditions. When pharmacological agents are prescribed, they should be explained as agents to correct these irregularities and not as tranquillizers. One cannot expect to make every doctor skilled in individual psychotherapies, but basic principles of behavioral management, counseling and communication skills can be imparted to every medical professional.
Making psychiatry a compulsory subject with at least six weeks of clinical training and examination is likely to equip any doctor with these skills. Teaching of psychiatry at post-graduate level of every clinical subject should also be seriously considered. In post-graduate psychiatric training and examination, the importance given to consultation - liaison psychiatry should be enhanced to meet the challenges and needs in this area. The consultation- liaison work between psychiatrists and specialists in other clinical subjects should be strengthened. Only with these policy changes, the medical profession will be able to meet the unseen but vast need in healthcare.
"Writing prescriptions is easy, understanding people hard!" -Franz Kafka
RERERENCES
1. Quill TE. Somatization Disorder- one of medicine's blind spots. JAMA 1985;254:3075-9. 2. Mayou R, Levenson J, Sharpe M. Somatoform disorders in DSM-V. Psychosomatics 2003;44:449-51. 3. Slater E. Diagnosis of "hysteria". Br Med J 1965;1:1395-9. 4. Perley MJ, Guze SB. Hysteria—the stability and usefulness of clinical criteria. A quantitative study based on a follow-up period of six to eight years in 39 patients. N Engl J Med 1962;266:421-6. 5. Barsky AJ. A comprehensive approach to the chronically somatizing patient. J Psychosom Res 1998;45:301-6. 6. DSM III R-American Psychiatric Association-Diagnostic and statistical Manual of Mental Disorders. 3rd Revised ed. Washington DC: APA; 1987. 7. Chaturvedi SK, Bhandari S, Beena MB, Rao S. Screening for abnormal illness behaviour. Psychopathology 1996;29:325-30. 8. Gask L. Management in primary care. In Treatment of Functional Somatic Symptoms. Oxford Univ Press; 1995. 9. Balint M. The doctor, his patient and the illness. Pitman, London: 1964. 10. C Bass and S Benjamin, The management of chronic somatization, British Journal of Psychiatry 162 (1993), pp. 472–480. 11. Bass C, Murphy MR. Somatization disorder: Critique of the concept and suggestions for future research. In Bass C, editor. somatization: Physical symptoms and psychological illness. Oxford: Blackwell; 1990. 12. Sharpe M, Mayou R, Bass C. Concepts, theories and terminology. In Treatment of Functional Somatic Symptoms. Oxford Univ. Press; 1995. 13. Sell HL, Murthy SR, Seshadri A, et al. Recognition and management of patients with functional complains (Psychosocial problems, ill defi ned somatic complains). A training package for primary-care physician. In: Sartorius D, Goldberg G, de Girolamo, et al. editors. Psychological disorders in general medical settings. WHO/Hogrefe and Huber, Toronto: 1990. p. 189-200. 14. Raguram R, Weiss MG, Channabasavanna SM, Devins GM. Stigma, depression, and somatization in South India. Am J Psychiatry 1996;153:1043-9. 15. DSM IV - American Psychiatric Association-Diagnostic and statistical Manual of Mental Disorders. 3rd Revised ed. Washington DC: APA; 1994.Psychosomatics1992;33:55-61. 16. Nambi SK, Prasad J, Singh D, Abraham V, Kuruvilla A, Jacob KS. Explanatory models and common mental disorders among patients with unexplained somatic symptoms attending a primary care facility in Tamil Nadu. Natl Med J India 2002;15:331-5. 17. Malhotra V, Singh S, Tandon OP, Sharma SB. The benefi cial effect of yoga in diabetes. Nepal Med Coll J 2005;7:145-7. 18. Trivedi JK, Mishra M, Kendurkar A. Depression among women in the South-Asian region: The underlying issues. Affect Disord 2007;102:219. 19. Paralikar VP, Agashe MM, Sarmukaddam SB, Dabholkar HN, Gosoniu D, Weiss MG. Biomedical markers and psychiatric morbidity of neurasthenia spectrum disorders in four outpatient clinics in India. Indian J Psychiatry 2008;50:87-95. 20. Sharpe M, Carson A."Unexplained" somatic symptoms, functional syndromes, and somatization: Do we need a paradigm shift? Ann Intern Med 2001;134:926-30. 21. Sharpe M. Rethinking somatization. Adv Mind Body Med 2001;17:260-3.
Abraham Kallivayalil Roy Department of Psychiatry Co-operative Medical College Cochin - 683 503.
Punnoose P. Varghese Govt Medical College Kottayam - 686 008, India 38 Indian research in last six decades
Ashish Srivastava, Sreejayan K., Anup M. Joseph, P. S. V. N. Sharma
ABSTRACT
The objective of this paper is to provide a review on the psychiatric comorbidity research in India based on the data published in the last six decades. The comorbidity data world over reflects that it is a much more common phenomenon than observed in routine clinical practice. In India, research into this domain of psychiatry has been limited, with comorbidity reported to be as high as 60%. In the few publications in this area, most of the authors have looked into substance related comorbidity. Small numbers of studies have looked into comorbid conditions in child psychiatry, especially mental retardation and very few studies have looked at other comorbidities. The landmarks in the studies in the area of psychiatric comorbidity have been highlighted in this review article.
Key words: Comorbidity, India, last six decades, Psychiatry
INTRODUCTION
The term comorbidity was first introduced by Feinstein in 1970 to denote those cases in which a 'distinct additional clinical entity' occurred during the clinical course of a patient having an index disease.[1] Psychiatric comorbidity may be defined as the co-occurrence of two psychiatric disorders in any combinations in the same person. They may occur simultaneously or sequentially. However, it does not necessarily imply that one is caused by the other. These individuals form an important and challenging subset of population associated with poorer outcomes in various clinical domains, including increased risk of relapse, re-hospitalization, life events, suicide and violence, medical comorbidity, homelessness, family discord,[2] economic burden and public healthcare delivery system burden. [3,4] Hence, such a population requires a more proactive outreach throughout the mental health care system. However, the situation seemed to be opposite till last few years. Individuals with co-occurring psychiatric disorders are often perceived to be 'system misfits' who have more than one disorder in systems of care that are designed as if everybody had one disorder at any given time.[5] Over the last two decades or so, the multifactorial complexity of comorbidity has been examined in various ways, viz. that individuals actually suffer from multiple disorders, all disorders are offspring of a defective persona, there is one common biological mechanism which leads to more than one disorder, and that disorders are reactions of the individual vulnerabilities to noxious stimuli.[6,7] In this light, there has been increased interest shown by researchers worldwide in the area of comorbidity. Psychiatric comorbidity has been frequently reported in the western literature, the US National comorbidity survey reported 51% of the patients with a diagnosis of major depression had atleast one comorbid anxiety disorder and only 26% had no other comorbid mental disorder.[8]
Similar results have been obtained from the Australian National survey of Mental Health and wellbeing.[9] Comorbidity issues have seemingly been less explored in Indian literature. In the present article, an attempt has been made to review articles relating to comorbidity, which have been researched and published in the Indian Journal of Psychiatry in the last six decades and a few other Indian medical journals and to elaborate on certain important observations.
SUBSTANCE USE AND COMORBIDITY
To compare substance use in mentally ill and the normal population Dube et al.[10] conducted a study in Agra as early as 1962. A total of 29,500 subjects were evaluated out of which 382 patients were "habitual intoxicant users".
The prevalence of substance use was low in the group (0.12%). Details of the pattern of substance use were not assessed in the study. There were 701 mentally ill subjects. Among the substance users the most common substance used was alcohol (62.36%) followed by cannabis (18%). Mentally ill patients were more likely to use multiple substances (30% vs. 16 %). Those using single substance used cannabis more commonly (30%). Both groups used cannabis in the form of bhang more than ganja. Use of opioids was not very common. Nicotine use was not included in the study. In this study, mentally ill were three times more likely to use substance compared to normal people. Patients with psychotic illness were 4.5 times more likely to use substances compared to the normal population. Patients with psychotic illness were three times more likely to use substances compared to those with neurotic illness. Specific life time prevalence was more in patients with bipolar affective illness compared to schizophrenia.
Cannabis has been socially accepted substance in India and has been used in traditional Indian medicine. The psychological consequences of chronic cannabis use have been studied by many Indian researchers. In India it was Dhunjbhoy,[11] who first described what he thought, was "Indian hemp insanity". Chopra and Chopra[12] concluded that regular cannabis use does not lead to mental derangement or psychosis, whereas Varma[13] and Thacore[14] reported that regular long term use of cannabis can lead to what is described as "Cannabis psychosis" (Varma, 1972) and "Bhang Psychosis" (Thacore, 1973). In a study, Bagadia et al.[15] analyzed 20 patients who were taking cannabis regularly; 95% of the subjects were males. It was found that majority of the patients i.e. 17 (85%) had disturbed mental health prior to cannabis consumption. 10 (50%) had schizophrenia, two (10%) were suffering from depression while five (25%) had anxiety disorder and two (10%) had premorbid dissocial personality disorder. The sample was collected from the 2000 new patients, relatives and friends attending the out patient department of psychiatry.
Trivedi et al.[16] screened 1000 consecutively presenting patients in a psychiatric hospital and screened them for drug abuse by self report. 16.4% of the patients were drug abusers. In considerations of individual drugs they found that 8.3% of our patients had abused alcohol, 5% cannabis, 2% minor tranquillizer and 0.7% and 0.4% barbiturate and opium respectively. Alcohol was significantly more abused in bipolar subjects and neurotics. Further, cannabis was more abused in schizophrenics and bipolar patients. Although a minor tranquilizer sample showed evidence of higher abuse among patients with schizophrenia and neurotic disorder, yet the difference was not significant.
Kishore et al.[17] assessed the lifetime prevalence of comorbidity in 43 patients with substance dependence and the chronology of such comorbidity, using an observational, analytical retrospective study design. The sample was recruited from the de-addiction center of a tertiary hospital at Lucknow. Most common substances used were alcohol (65%) and opioids (56.5%). 60% of the subjects had more than one diagnosis. The commonly co-occurring disorders were mood disorders (35%), sexual dysfunctions (23%), psychotic disorders (11.5%) and anxiety disorders (3.5%). 53.8% with opioid dependence and 30.8% with alcohol dependence had personality disorders. 72.7% of the patients with a diagnosis of Axis II also had an Axis I diagnosis, while 46.9% of those without a personality disorder had Axis I disorders. In five out of nine patients, the mood disorder came primary to the psychoactive substance dependence, four of these patients having dysthymia. In the remaining four patients with mood disorders, substance dependence had preceded the mood disorder in terms of chronology of development. Similarly, in the one patient with schizophreniform disorder, the psychotic episode developed after he had already developed alcohol dependence, the latter thus being the primary diagnosis.
Goswami et al.[18] examined the relationship of the courses of substance use and schizophrenic symptomatology in substance abusing "dual-diagnosis" patients with schizophrenia. They concluded that substance use disorder preceded the onset of schizophrenic illness in the majority, and that increase in substance abuse preceded schizophrenic exacerbation in one-third of dual- diagnosis patients. However, overall, they found no evidence that the course of substance use was associated with that of schizophrenia after both disorders were diagnosed.
In a group of 70 patients with schizophrenia, Aich et al.[19] found that 54.3% had comorbid substance abuse. Cannabis and nicotine were the commonly abused drugs followed by alcohol. On the sociodemographic profile the schizophrenic patients who abused drugs did not differ from the ones who did not. It was seen that substance abusing schizophrenics were clustered in the positive syndrome group and that non-substance abuse schizophrenics clustered in the negative and mixed syndrome group.
In another study on 30 subjects with alcohol dependence, by Vohra et al.[20] 23 (76.6%), patients were found to have comorbid psychiatric disorder. The axis - I comorbidty was found in 76.6% patients. Axis - II comorbidity was seen in 40% of the sample. Cluster B personality disorders accounted for the maximum (58.3%) axis - II comorbidity. Major depressive disorder was diagnosed 52.1% of patients.
In a study examining the comorbidity in alcohol dependence by Singh H.N. et al.[21] the prevalence of psychiatric disorders was found to be 92% compared to 12% in controls. The most common disorders were depression (26%), dissocial personality disorder (21%) and phobias (16%).
MOOD DISORDER AND COMORBIDITY
Hundred subjects who met the criteria for current manic episode were recruited from a psychiatric hospital and were evaluated for substance abuse by Suresh et al.[22] 50% of the subjects had comorbid substance abuse. The commonest drug abused was alcohol with 23.8% at abuse level and 14.9% at dependence level. Prevalence of cannabis used disorders was 26.7%, sedative- hypnotics 4%, cocaine 3%, nicotine 10% and polysubstance abuse 3%. Substance abuse was the single most consistent factor found to be associated with poor outcome of mania.
Mendhekar and Mehta[23] published a case report documenting the presence of multiple paraphilias during a manic episode in a 60-year-old male subject. The authors suggest that in mania, lack of proper sexual outlet and social boycott might be the contributory factors for exhibiting abnormal sexual behavior. Gupta and Basu[24] reported a case of recurrent mania secondary to alcohol intake and with a similar family history. The report highlighted the potential role of alcohol as a mania inducing agent.
SCHIZOPHRENIA AND DEPRESSION
S.S. Raju[25] studied the comorbidity of depressive disorders in schizophrenia. Of the 529 patients with schizophrenia recruited into the study, 34% were found to have depressive symptoms. After eight weeks of treatment with neuroleptics, in 47% of the patients the depressive symptoms abated. These patients were followed up for six to 48 months; 10% of the subjects developed major depressive disorder in presence of residual symptoms; 25% of patients with residual symptoms developed depressive symptoms not amounting to a syndrome; 3% developed schizo-affective disorders; 2% of the patients in whom the schizophrenic symptoms had remitted, developed major depressive disorder and 53% of the subjects who developed depressive symptoms on follow-up had no such symptom at the onset of schizophrenic illness.
MENTAL RETARDATION AND COMORBIDITY
A study conducted in the child psychiatry unit of a tertiary psychiatric hospital by Khess R.J. et al.[26] evaluated the comorbidity in children with mental retardation-57% of the subjects had some psychiatric co morbidity. The comorbidities found were mood disorder (8%), hyperkinetic disorder (14%), autism (11%), psychosis (11%), conduct disorder (2%) enuresis (2%) and unspecified emotional and behavioral disorder (26 %). Mood disorders were found to be common in children with mild level of mental retardation. It was observed that patients with a psychiatric disorder had a milder level of retardation compared to patients with a medical illness. The psychiatric illness and medical illness did not co exist frequently.
In a cross sectional study, Bhattacharyya et al.[27] found that contrary to the conventional belief, individuals diagnosed with Down syndrome had higher frequency of behavioral abnormalities such as impulsivity and stereotypies compared to the normal population.
Greydanus and Pratt[28] in a review of syndromes associated with mental retardation mentions the externalizing behavior problems seen in these individuals. Adolescents with severe Mental retardation often exhibit self stimulatory and self injurious behavior patterns apart from mild to severe tantrums. The authors opine that the caregivers should make efforts to minimize the youth's capacity for self harm. They further state that youths with mild mental retardation constitute the highest risk group for engaging in high risk sexual behavior and becoming victims of physical, sexual and mental abuse. Depressive disorders in adolescents with mental retardation confer an increased risk for illness and interpersonal difficulties apart from an increased risk for substance abuse and suicidal behavior. The authors underscore the risks of not detecting and treating depression in this group of youth.
ATTENTION DEFICIT HYPERACTIVITY DISORDER AND SPECIFIC LEARNING DISORDERS
Karande et al.[29] documented the clinical profile and academic history of children with specific learning disability and co-occurring ADHD. They found that all the children in their study had poor academic performance and about 40% of the sample had developed aggressive or withdrawn behavior. The authors also found no significant gender differences in the clinical profile. Karande and Bhosrekar[30] evaluated the impact of co-occurring attention deficit hyperactivity disorder (ADHD) on the health-related quality of life (HRQOL) of children with newly diagnosed specific learning disability (SpLD). A little more than a quarter of the 150 children enrolled in the study had co- occuring ADHD. The study indicated that co-occurring ADHD adversely affected the HRQOL of children with SpLD and highlighted the importance of treating co-occurring ADHD effectively to improve the psychosocial health of such children. In an editorial, Susan Crawford felt that a lack of awareness was a major reason for disorders such as specific learning disabilities (SpLD) and attention-deficit hyperactivity disorder (ADHD) in children to go unidentified in India.[31]
PERVASIVE DEVELOPMENTAL DISORDER AND COMORBIDITY
Girimaji SR et al.[32] at NIMHANS, Bangalore studied comorbid psychiatric disorders in children with pervasive developmental disorders. In the sample of 50 children, comorbidity was evident in 46%. The common comorbid conditions observed were attention deficit hyperactivity disorder, anxiety disorder including obsessive compulsive disorder, bipolar affective disorder and circadian disturbance of sleep. There was a significant group of cases with subsyndromal comorbid diagnoses.
CONCLUSION
Evaluation and diagnosis of comorbid disorder is of paramount importance in order to modify treatment schedules and improve patient outcomes. In the present times, comorbid diagnosis should be an expectation and not an exception. Studies have consistently shown in the past that appropriate psychopharmacology of a known psychiatric disorder ensures better outcome for both the index mental illness and comorbid diagnosis with special reference to substance use. At the same time we now have some literature bringing out the fact that the treatment of both index and comorbid conditions is necessary, for example, integrated mental health and substance abuse treatment is the best treatment practice. Treatment of patients with comorbid diagnosis should be individually matched and based on assessment of diagnoses, level of disability, stage of change, treatment, rehabilitative goals or strengths, and level of care. Treatment should also be stage specific including individual and family interventions, community reinforcement and contingency management. Each of these areas need further research in relation to specific comorbidity combinations. It can be seen that the research so far has started to address some of the above issues but many of them remain unexplored.
REFERENCES
1. Feinstein AR. The pre-therapeutic classification of co-morbidity in chronic disease. J Chronic Dis 1970;23:455-68. 2. RachBeisel, Scott J, Dixon L. Co-occuring severe mental illness and substance use disorders. A review of recent research. Psychiatr Serv 1999;5:1427-534. 3. Hartman E, Nelson D. A case study of statewide capitation: The Massachusetts experience. In: Minkoff K, Pollack D, editors. Managed Mental Health Centre Care in the Public Sector: A Survivor manual. Amsterdam: Harwood Academic Publishers; 1997.p. 59-76. 4. Quinlivan R, McWhirter DP. Designing a comprehensive care program for high cost clients in a managed care environment. Psychiatr Serv 1996;47:813-5. 5. Minkoff K. An integrated model for the management of co-occuring psychiatric and substance disorders in managed care systems. Dis Manag Health Out 2000;8:251-7. 6. Van Praag HM. Comorbidity (psycho) analysed. Br J Psychiatry 1996;30:129-34. 7. Desai NG. Comorbidity in Psychiatry: Way forward or a conundrum? Indian J Psychiatry 2006;48:75-7. 8. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8-19. 9. Andrews G, Slade T, Issakidis C. Deconstructing current comorbidity: Data from the Australian National Survey of Mental Health and well-being. Br J Psychiatry 2002;181:306- 14. 10. Dube KC, Handa SK. Drug habit in health and mental disorders. Indian J Psychiatry 1969;11:23-9. 11. Dhunjiboy JE. A brief resume of the types of Insanity commonly met with in India with a full description of "Indian Hemp Insanity" peculiar to the country. J Ment Sci 1930;75:254. 12. Chopra RN, Chopra IC. Drug Addiction with special reference to India. Council of Scientific and Industrial Research, New Delhi, 1965. 13. Varma LP. Cannabis Psychosis. Indian J Psychiatry 1972;I4:241. 14. Thacore VE. Bhang Psychosis. Br J Psychiatry 1973;123:225-9. 15. Bagadia VN, Copalani J, Pradhan PV, Shah LP. Habitual use of cannabis Indica in psychiatric patients. Indian J Psychiatry 1976;18:141-6. 16. Trivedi JK, Sethi BB. Drug abuse in psychiatric patients. Indian J Psychiatry 1978;21:345-8. 17. Kisore P, Lal N, Trivedi JK, Dalal PK, Aga VM. A Study of comorbidity in psychoactive substance dependence patients. Indian J Psychiatry 1994;36:133-7. 18. Goswami S, Singh G, Mattoo SK, Basu D. Courses of substance use and schizophrenia in the dual-diagnosis patients: Is there a relationship? Indian J Med Sci 2003;57:338-46. 19. Aich TK, Sinha VK, Khess CR, Singh S. Demographic and clinical correlates of substance abuse comorbidity in schizophrenia. Indian J Psychiatry 2004;46:135-9. 20. Vohra AK, Yadav BS, Khurana H. A study of psychiatric comorbidity in alcohol dependence. Indian J Psychiatry 2003;45:247-50. 21. Singh HN, Sharma SG, Pasweth AM. Psychiatric comorbidity among alcohol dependents. Indian J Psychiatry 2005;47:222-4. 22. Sureshkumar PN, Raju SS. Impact of substance abuse comorbidity on psychopathology and pattern of remission in mania. Indian J Psychiatry 1998;40:357-63. 23. Mendhekar DN, Mehta R. Mania associated with multiple paraphilias. Indian J Med Sci 2006;60:28-9. 24. Gupta N, Basu D. Mania secondary to alcohol binge. Indian J Med Sci 1997;51:394-5. 25. Raju SS. Depressive disorders in schizophrenia. Indian J Psychiatry 1986;28:109-18. 26. Khess CR, Dutta I, Chakrabarty I, Bhattacharya P, Das J, Kothari S. Comorbidity in children with mental retardation. Indian J Psychiatry 1998;40:289-94. 27. Bhattacharyya R, Sanyal D, Roy K, Saha S. A study of cluster behavioral abnormalities in Down syndrome. Indian J Med Sci 2009;63:58-65. 28. Greydanus DE, Pratt HD. Syndromes and disorders associated with mental retardation. Indian J Pediatr 2005;72:859-64. 29. Karande S, Satam N, Kulkarni M, Sholapurwala R, Chitre A, Shah N. Clinical and psychoeducational profile of children with specific learning disability and co-occurring attention-deficit hyperactivity disorder. Indian J Med Sci 2007;61:639-47. 30. Karande S, Bhosrekar K. Impact of attention-deficit/hyperactivity disorder on health- related quality-of-life of specific learning disability children. Indian J Pediatr 2009. [Epub ahead of print] 31. Crawford SG. Specific learning disabilities and attention-deficit hyperactivity disorder: Under-recognized in India. Indian J Med Sci 2007;61:637-8. 32. Girimaji SR, Biju ST, Srinath S, Seshadri SP. Co morbid psychiatric disorders in pervasive developmental disorders. J Indian Assoc Child Adoles Ment Health 2005;1:7.
Ashish Srivastava Sreejayan K. Anup M. Joseph P. S. V. N. Sharma Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka - 576 104, India 39 An overview of Indian research in personality disorders
Pratap Sharan
ABSTRACT
Personality disorders have significant, but often unrealized, public health importance. The present review summarizes the published work on personality disorders in the Indian population or by Indian researchers residing in the country. Researchers who have worked on assessment methodology in India have demonstrated that clinical diagnosis has a low reliability when compared with semi-structured interviews; and have attempted to increase the feasibility of the standardized use of International Personality Disorder Examination, a semi-structured interview developed by the World Health Organization (WHO). Studies on epidemiology demonstrate that none of the general population studies have employed standardized interviews, and hence, they grossly underestimate the prevalence of personality disorders in the community. The clinical epidemiology studies have employed questionnaires and interviews developed in the West, mostly without local adaptations, with discrepant results. However, these studies show that personality disorders are common in the clinical population and that rates vary across sub populations. While, there are a few reports attesting the theoretical importance of the role of culture in the formation and expression of personality disorders, empirical literature from India in this area is scanty. Similarly, there are few reports on the treatment of personality disorders, while, important areas such as service delivery, etiology, and validity of personality disorders, are unaddressed. The study of personality disorder in India is maturing, with researchers showing increased familiarity with the methodological nuances of this complex area of research.
Key words: Personality disorders, research, epidemiology INTRODUCTION
The definition of personality disorders given by the International classification of diseases (ICD-10) states that 'personality disorders' comprise of deeply ingrained and enduring behavioral patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent extreme or significant deviation from the manner in which an average individual in the given culture perceives, thinks, feels, and particularly relates to others. They are frequently, though not always, associated with varying degrees of subjective distress and problems in social functioning and performance. These patterns are usually evident during late childhood or adolescence, but the requirement to establish their stability and persistence usually (but not necessarily) restricts the use of the term 'disorder' for adults.[1] The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) definition is similar, although it is more explicit, and emphasizes the impulse control problems that many patients with personality disorders would have.[2]
Personality disorders lead to a disturbance in functioning as great as that in most major mental disorders.[3] They are associated with high rates of separation and divorce; unemployment and inefficiency; and poor quality of life for the individual and his/her family. Patients with personality disorders have an increased risk of mortality through suicide, homicide, and accidents. Moreover, when a personality disorder is present, the treatment of other coexisting psychiatric or medical conditions is frequently more complicated, lengthier, or less successful; a pattern that may at times be due to lack of recognition of the personality disorder.[4-6]
Since the publication of the Diagnostic and Statistical Manual (DSM-III) in 1980, and its creation of a separate diagnostic axis (i.e., Axis II) for personality disorders, interest in the description and classification of personality disorders has expanded dramatically in the West. The present review summarizes the published work on personality disorders in the Indian population or by Indian researchers residing in the country. It excludes studies on normal personality variants and studies that use personality measures in relation to other foci of interest.
STUDIES ON HISTORY
Neki states that the proposition that human beings are different in their personality style evolved from antiquity.[7] Charaka applied the Tri-guna theory to the clinical situation and postulated that man's prakriti (nature) was defined by the relative accentuation of any of the three gunas: Satvik (consciousness), rajsik (energy) or tamsik (inertia). STUDIES ON ASSESSMENT METHODOLOGY
The field of personality disorders is beset with problems of reliability and validity. The reliability of the personality disorder diagnoses, when assessed without diagnostic instruments is lower than state disorder (Axis I) diagnoses. Furthermore, the reliability across personality disorder instruments, particularly between self-report instruments and semi- structured interviews; is low, such that self-report instruments are considered good only for screening personality disorders.[8] Naidu and Issac found that only 36.3% of the psychiatric inpatients, diagnosed to have a personality disorder clinically, also had a personality disorder diagnosis according to a semi-structured interview schedule (SCID II), attesting to the low reliability of clinical diagnosis. [9] However, the authors did not specify whether SCID II was standardized for use in India. This is relevant because some unreliability could have been introduced by difficulties in cross-cultural application of a Western instrument.
A number of assessment instruments for the diagnosis and measurement of personality disorders are now available for clinical and research use in the West. Some of these focus on individual personality disorders such as schizotypal, borderline or depressive, while others are comprehensive in their coverage. Among the latter, both self-rating instruments useful for screening purposes, such as, Personality Disorder Questionnaire (PDQ)[10] and Millon Clinical Multiaxial Inventory (MCMI)-III;[11] and semi-structured interview-based instruments, such as, Structured Clinical Interview for DSM- III R Axis II (SCID-II)[12] and International Personality Disorder Examination (IPDE) are available.[13] The latter provides ICD-10 diagnoses. Although it has good psychometric properties, its length makes it difficult to use in the community, in population research, particularly outside the psychiatric settings. Mann et al., evaluated the utility of the informant-based Standard Assessment of Personality (SAP) as a screen for the International Personality Disorder Examination (IPDE), in out-patients in Bangalore.[14] The overall agreement between the two instruments in the detection of ICD-10 personality disorder was modest (kappa 5 0.4). The level of agreement varied according to the personality disorder category, ranging from kappa 0.66 (dependent) to kappa 0.09 (dyssocial). The SAP proved to have a high negative predictive value (97%) for IPDE as the gold standard, suggesting its potential as a screen in samples where the expected prevalence of personality disorder was low. However, Loranger et al. have developed a screening questionnaire for the IPDE, therefore, the relative advantage of the SAP as a screen for IPDE needs to be re-established.[13]
Although SAP and IPDE screening questionnaires address the issue of brevity, they are not standardized for use in the local languages of India. Sharan et al., translated the ICD-10 IPDE into Hindi following a standard translation protocol, and established the joint rater reliability and applicability of the Hindi version in non-psychotic adult outpatients.[15] The average intraclass correlation of each item (0.89), the number of criteria met per disorder (0.92), and the dimensional scores (0.98) were high. Kappa for definite (0.65 to 0.78) and probable (0.78 to 1.00) personality disorder and for the presence/absence of any personality disorder (0.78) was acceptable. The overall weighted kappa was 0.81 for definite and 0.91 for probable personality disorder. The patients experienced difficulty in understanding questions related to self-image, internal preferences, emptiness, and emotional shallowness. Further, the interviewers faced difficulty in scoring certain items because of cultural variation in what can be considered a norm, for example, the avoidance of occupational behaviors that involve interpersonal contact (difficult to label abnormal in housewives), encouraging/allowing others to make important decisions (difficult to label abnormal in many women/young adults), unwillingness to become involved with persons unless they were certain of being liked (difficult to label abnormal in persons who miss out on relationships with members of the opposite sex), hitting family members (difficult to label abnormal as norm varies); lying (difficult to label abnormal as no norm is specified), and speeding/reckless driving (difficult to label abnormal in those who do not own a vehicle). However, overall, the results suggested that ICD-10 IPDE (Hindi Version) has acceptable joint rater reliability and applicability in the North Indian Hindi speaking population.
STUDIES ON EPIDEMIOLOGY
Community studies
Four general population studies done in the late 1980s and early 1990s that used assessment instruments specific to personality disorders established the high (and consistent) prevalence of these disorders (10.3 to 13.5%) in developed countries.[16] More recent studies have upheld these results. The sex ratio was different for specific types of personality disorders, although the overall rate of prevalence was roughly equal for the two sexes.[17] Reddy and Chandrashekar conducted a meta-analysis of 13 epidemiological studies from different parts of India.[18] The prevalence of personality disorders was assessed in seven studies and the rate varied from 0 to 2.8%, with the weighted prevalence rate being 0.6%. Personality disorder diagnosis was significantly associated with the male gender. Prevalence rates of personality disorders may be lower in developing countries, but the methodological shortcomings of surveys preclude direct comparisons with the western data. Most of the general population epidemiological studies conducted in India have neglected co-morbidity and dual diagnosis, and have used screening instruments with low sensitivity and single informants; hence, they systematically underreport the prevalence.[19]
Clinical studies
Early studies (that did not employ diagnostic instruments or operationalized criteria) on clinical samples from India reported prevalence rates of 0.3- 1.6%.[20-23] However, the rates were higher in special populations such as university students (19.1%);[22] criminals (7.3-33.3%);[24-26] patients with substance use disorders (20-55%);[27-29] and patients who attempted suicide (47.8-62.2%).[30,31] Studies employing comprehensive protocols for assessment (which were, however, not standardized for use in the Indian population) have yielded high rates of personality pathology in patients with anxiety disorders, such as, social phobia;[32] drug dependence (25.6%);[33] and mood disorders (37.5% in patients with bipolar disorder and 40.8% in those with major depressive disorder).[34] The study on mood disorders used a self-report format for assessing personality disorders, which is known to overestimate the prevalence of these disorders.[34]
In the International Pilot Study of Personality Disorders (IPSPD), the following personality disorders were frequently diagnosed in the clinical sample at Bangalore: Schizotypal (19.1%) and borderline (14.7%) according to the DSM- III-R system; and emotionally unstable (8.6%) according to the ICD-I0 system.[13] Banerjee and Mitra compared 50 teenage girl outpatients with academic difficulties with normal controls.[35] About 30% of the index group had emotionally unstable personality disorder (impulsive type), 6% had dependent personality disorder, and 6% other personality disorders, according to the ICD-10. The authors did not report whether they used the IPDE screen or the interview for diagnosing personality disorders.
Studies in relation to self-harm
The rate of personality disorders in subjects who have demonstrated acts of self-harm have varied from 7%[36] to 64%. [37] Methodological issues probably play a major role in the discrepancy of prevalence rates between studies. Nath et al., used the International Personality Disorder Examination (IPDE) to assess outpatients and inpatients, who presented with a history of self-harm at any point in their life, in two age groups (15-24 years and 45-74 years).[37] Sixty-four percent of the older group and 58.5% of the young subjects were reported to have a personality disorder. In the young group the most common personality disorder was the emotionally unstable personality disorder (28.6%) and anankastic personality disorder (11.7%); while in the older group, the anankastic personality disorder (34.5%) and emotionally unstable personality disorder (13.8%) were the most common personality disorders. The fact that all patients could be interviewed despite reluctance on the part of some (due to medico-legal concerns), and because the interview took approximately one (which is shorter than usual for those with a positive diagnosis), suggests that the subjects may have responded with a affirmative bias toward the questions. The fact that a local language version of the IPDE was not yet available, May also have led to some randomness in the responses. That only 5% of the young and none of the older patients had more than one personality disorder diagnosis, was surprising, in light of the high prevalence of personality disorders.
Chandrasekaran et al., assessed 341 survivors (93% of all survivors, over a one- year period) after their first suicide attempt from a general hospital.[36] Only 7% received a personality disorder diagnosis according to ICD 10 IPDE. The inclusion of the first attempt cases may have led to a low rate of diagnosis of emotionally unstable personality disorder (and consequently of any personality disorder). Other systematic biases could have been introduced by use of two interviewers and consensus diagnosis for all cases (the diagnostic process may have become too stringent. The article does not explicitly state it, but it is probable that the authors used the IPDE screening questionnaire for selecting subjects for the full interview; the sensitivity of the screen should have been assessed/mentioned to help in the interpretation of the findings of the study. The authors have quoted a study by Latha et al., which yielded a (similar) prevalence rate of 12% for personality disorders in those attempting self-harm, but the latter study reached a diagnosis without using a standardized instrument and hence the two studies are not strictly comparable.[38] A study that only assessed the presence of borderline personality disorder with a semi-structured interview, in patients who had made a suicide attempt, yielded a much higher rate of 18.3% for this single diagnosis.[39]
An interesting observation in clinical epidemiology of personality disorders in India is the relatively narrow gap in prevalence between the genders, with respect to emotionally unstable personality disorders. This could be due to the inclusion of emotionally unstable personality disorder — impulsive type in ICD 10, patterns of treatment seeking or the impact of cultural factors on the formation and expression of these disorders. An examination of the gender differential in community studies would be needed to confirm/disconfirm this interesting finding obtained in the clinical studies.
Classification system preferred in Indian research
The ICD-10 and DSM-IV are different, but overlapping classification systems. Both have adopted a polythetic approach as against a monothetic approach, in which none of the listed criteria are essential to make a diagnosis, any combination of a required number of criteria would lead to the diagnosis. There are some differences in the nomenclatures, for example, Anankastic personality disorder in ICD-10 is obsessive-compulsive personality disorder in DSM-IV. In ICD- 10, schizotypal disorder is considered to be an attenuated manifestation of schizophrenia and is categorized with psychotic disorders, while, narcissistic, depressive, and passive-aggressive personality disorders do not find a mention. There are also several marked differences in the criteria of the two systems and some minor variations in the wordings. Finally, the two schemes differ, in that, DSM separates state- and trait-based disorders on two axis and provides for clusters of personality disorders; while the ICD-10 diagnostic guidelines do not place the personality disorders and state disorders on separate axes or subdivide personality disorders into clusters. It is obvious from the above-mentioned studies that ICD 10 has found greater favor with the Indian researchers, probably because of its easier application in clinical practice (retrospective studies) and greater accessibility of IPDE, as it was developed by the World Health Organization.
Studies on cultural issues
Western authors such as Oldham state that there is little dispute about the existence of personality pathology. [4] The International Pilot Study on Personality Disorders demonstrated that disorders, as presently defined, could be identified at all sites (multinational, multilingual, multicultural). [40] However, these studies do not confirm the cross-cultural validity or usefulness of western diagnostic categories or personality dimensions, as these utilize western concepts in a non-western setting. Thus, they may have identified ethnic artifacts rather than culturally meaningful configurations.[41] Personality disorders typically carry a strong connotation of immutability that may be directly at odds with the core belief of some of the major non-western cultural traditions, which lay emphasis on the perfectability of human nature.[7] At an even more fundamental level, cross- cultural analysis has challenged concepts such as 'person' and 'selfhood,' implicity or explicitly used by theories of personality. Shweder and Bourne have described the sociocentric, holistic conception of individual society relations among Oriyas, where person units are believed to be altered by the relations into which they enter, rather than being seen as a synthesis of abstract traits.[42] Similar relational concepts of the person are reported widely in India.[43]
It has been hypothesized that culture can influence: (i) The genetic selection of specific temperamental characteristics in highly inbred groups, (ii) Learnings inside and outside the family, (iii) The threshold when personality vulnerability cannot be compensated by the person (trait accentuation), and (iv) The social threshold when such decompensations are labeled pathological.[44,45] Ethnocentric work is clearly needed before the universality of personality disorders is assumed. In an article of this kind, Chowdhury and Brahma presented a case of an 18-year old man with dhat syndrome with repeated self-harm attempts initially in response to guilt caused by masturbation and voyeurism and then due to the occurrence of somatic symptoms that he associated with semen loss.[46] He was diagnosed to have borderline personality disorder according to the Self-Harm Inventory (SHI) and Personality Disorder Questionnaire-R (PDQ-R). However, more transcultural work from India is clearly required.
Studies on management issues
Management options will depend on a large number of factors, such as, the availability of healthcare resources, the therapist's own skill and stance, and aspects of the patient's personality and present situation. These include his/her social support, associated psychiatric or physical illness, psychological mind-set, past relationship patterns, and areas of resourcefulness. Pradhan et al., presented a one-year follow up of six male borderline patients treated with pharmacotherapy and psychotherapy, who improved substantially.[47] More literature on individual management and service provision for personality disorders is urgently needed to counter the prevalent nihilism with regard to treatment outcome. Western studies suggest that many patients maintain sustained improvement with treatment.
CONCLUSIONS
The field of personality disorders is at a nascent stage of development in India. From a situation of almost no articles specifically focused on personality pathology till the 1980s, there is now a trickle. However, to date, the focus is understandably but entirely on clinical epidemiology. Although there are very few methodologically robust studies, the increasing familiarity with the field and its methodological nuances augers well for the future. There is obviously a need for better and more studies in relation to personality disorders on methodology and epidemiology (particularly community studies), and also on cultural and classificatory issues. There is also a need for studies to populate the vast open swathes in terms of etiology, clinical features, assessment, management, course and outcome, and on the various debates that mark the personality disorder field, for example, whether personality disorders, as conceptualized today, are valid entities; the boundary issues between personality disorders and normal personality traits on the one hand and mental state disorders on the other; and the organization of personality disorder in dimensional or categorical terms. REFERENCES
1. World Health Organization. The ICD-lO classification of mental and behavioral disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994. 3. Nakao K, Gunderson JG, Phillips KA. Functional impairment in personality disorders. J Pers Disord 1992;6:24-33. 4. Oldham JM. Personality disorders: Current perspectives. JAMA 1994;272:1770-6. 5. Singh BK, Sharma G, Janardhan Reddy YC. Personality disorders: An update. Indian J Psychiatry 1999;41:11. 6. Sharan P, Kulhara P. Personality disorders. In: Bhugra D, Ranjith G, Patel V, editors. Handbook of psychiatry: A South Asian perspective. New Delhi: Byword Viva Publishers Private Limited; 2005. p. 297-322. 7. Neki S. A reappraisal of the 'Triguna' theory of personality. In: Neki J, Prabhu GG, editors. Personality development and personal illness. New Delhi: All India Institute of Medical Sciences; 1970. p. 1-6. 8. Zimmerman M. Diagnosing personality disorders: A review of issues and research methods. Arch Gen Psychiatry 1994;51:225-45. 9. Naidu H, Issac S. Personality disorders-diagnoses or alibi? Indian J Psychiatry 1999;41:64. 10. Hyler SE, Rieder RD, Williams JB. The personality diagnostic questionnaire, development and preliminary results. J Pers Disord 1988;2:229-37. 11. Millon T, Millon C, Davis RD. Millon clinical multiaxial inventory-Iii. Minneapolis: Computers Systems; 1994. 12. Spitzer RL, Williams JB, Gibbon M. User's guide for the structured clinical interview for DSM-III R. Washington DC: American Psychiatric Association Press; 1990. 13. Loranger AW, Janca A, Sartorius N. Assessment and diagnosis of personality disorders. The ICD-I0 International Personality Disorder Examination (IPDE). Cambridge: Cambridge University Press; 1997. 14. Mann AH, Raven P, Pilgrim J, Khanna S, Velayudham A, Suresh KP, et al. An assessment of the standardized assessment of personality as a screening instrument for the international personality disorder examination: A comparison of informant and patient assessment for personality disorder. Psychol Med 1999;29:985-9. 15. Sharan P, Kulhara P, Verma SK, Mohanty M. Reliability of the ICD-10 International Personality Disorder Examination (IPDE) (Hindi Version): A preliminary study. Indian J Psychiatry 2002;44:362-4. 16. de Girolamo G, Reich, JH. Personality disorders (epidemiology of mental disorders and psychosocial problems). Geneva: World Health Organization; 1993. 17. Reich JH, de Girolamo G. Epidemiology of DSM-III personality disorders in the community and in clinical populations. In: Loranger AW, Janca A, Sartorius N, editors. Assessment and Diagnosis of Personality Disorders. The ICD-l0 International Personality Disorder Examination (IPDE). Cambridge: Cambridge University Press; 1997. p. 18-42. 18. Reddy MV, Chandrashekar CR. Prevalence of mental and behavioral disorders in India: A meta-analysis. Indian J Psychiatry 1998;40:149-57. 19. Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92. 20. Davis RB, Gupta NC, Davis AB. The first ten years: Some phenomena in a private psychiatric hospital. Indian J Psychiatry 1965;7:231-42. 21. Marfatia JC. A survey of 2000 private adult mental patients. Indian J Psychiatry 1973;15:279-89. 22. Teja JS. Mental illness and family in America and India. Int J Soc Psychiatry 1978;24:225- 31. 23. Wig NN, Varma VK, Khanna BC. Diagnostic characteristics of a general hospital psychiatric adult outpatient clinic. Indian J Psychiatry 1978;20:262-6. 24. Somasundram D. The men who kill their wives. Indian J Psychiatry 1970;12:125-46. 25. Gupta SC, Sethi BB. Psychosocial aspects and personality patterns of murderers. Indian J Psychiatry 1974;16:111-20. 26. Singh G, Verma HC. Murder in Punjab: A psychosocial study. Indian J Psychiatry 1976;18:234-51. 27. Satija DC, Sharma DK, Gaur A. Prognostic significance of psychopathology in the abstinence from opiate addiction. Indian J Psychiatry 1989;31:157-62. 28. Sattar FA, Raju MS, Goyal S. Comorbidity in alcohol dependence syndrome. Indian J Psychiatry 1998;40:22. 29. Sohklet S, Sharma SG. A study of psychiatric morbidity among heroin addicts. Indian J Psychiatry 1998;40:18-9. 30. Sethi BB, Gupta SC, Singh H. Psychosocial factors and personality characteristics in cases of attempted suicide. Indian J Psychiatry 1978;20:25-30. 31. Gupta SC, Singh H. Psychiatric illness in suicide attempters. Indian J Psychiatry 1981;23:69-74. 32. Chatterjee S, Sunitha TA, Velayudhan A, Khanna S. An investigation into the psychobiology of social phobia: Personality domains and serotonergic function. Acta Psychiatr Scand 1997;95:544-50. 33. Kishore P, Lal N, Trivedi JK. A study of comorbidity in psychoactive substance dependence patients. Indian J Psychiatry 1994;36:133-7. 34. Naidu H, Thacore AS, Issac S. Personality disorders in mood disorders: Coexistence, diagnosis, stability and implication. Indian J Psychiatry 1998;40:38. 35. Banerjee KR, Mitra T. Decending academic performance in adolescent female students: Role of personality and social support. Indian J Psychiatry 2007;49:44. 36. Chandrasekaran R, Gnanaseelan J, Sahai A, Swaminathan RP, Perme B. Psychiatric and personality disorders in survivors following their first suicide attempt. Indian J Psychiatry 2003;45:45-8. 37. Nath S, Patra DK, Biswas S, Mallick AK, Bandyopadhyay GK, Ghosh S. Comparative study of personality disorder associated with deliberate self-harm in two different age groups (15-24 years and 45-74 years). Indian J Psychiatry 2008;50:177-80. 38. Latha KS, Bhat SH, D'Souza P. Suicide attempters in a general hospital unit in India: Their socio-demographic and clinical profile-emphasis on cross cultural aspects. Acta Psychiatr Scand 1996;94:26-30. 39. Nair S, Patil B, Pinto C. A study of borderline personality disorder in suicide attempters. Indian J Psychiatry 1997;39:55. 40. Loranger AW, Sartorius N, Andreoli A. The international personality disorder examination. Arch Gen Psychiatry 1994;51:215-24. 41. Lewiz-Fernandez R, Kleinman A. Culture, personality and psychopathology. J Abnorm Psychol 1994;103:67-7l. 42. Shweder RA, Bourne EJ. Does the concept of the person vary cross-culturally? In: Shweder RA, LeVine R, editors. Culture theory. New York: Cambridge University Press; 1984. p. 158-99. 43. Sinha D. Psychology in a third world country: The Indian experience. New Delhi: Sage; 1986. 44. Neki JS. Personality disorders: Some problems of nosology and classification. In: Neki JS, Prabhu GG, editors. Personality Development and Personal Illness. New Delhi: All India Institute of Medical Sciences; 1970. p. 117-27. 45. Paris J. Social factors in the personality disorders. Transcult Psychiatry 1997;34:421-52. 46. Chowdhury AN, Brahma A. A case of dhat syndrome with borderline personality disorder. Indian J Psychiatry 2004;46:373-4. 47. Pradhan PV, Shah H, Shivalkar R. Close encounter of a different kind. Indian J Psychiatry 1999;41:64.
Pratap Sharan Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India 40
Indian research on sleep disorders
Nilesh Shah, Abha Bang, Aparna Bhagat
ABSTRACT
Literature on sleep disorders from our country, India, can mainly be found in the Indian journal of Sleep medicine, Indian Journal of psychiatry, The Annals of Indian Academy of Neurology and certain other journals and books. The article highlights the contribution of various Indian doctors in the field of sleep disorders, which includes review articles, prevalence studies, studies on etiology and treatment options, case reports and a couple of case control studies. Also included are studies on various sleep related syndromes as well as studies about awareness and knowledge of sleep disorders amongst the medical fraternity. This is a humble attempt to compile the rich data available in the country on sleep disorders in order to aid further research in the field.
Key words: Sleep Disorders, Indian literature on sleep disorders.
INTRODUCTION
Sleep disorder literature from our country, India, is largely published in the Indian Journal of Sleep Medicine, Indian Journal of Psychiatry, The Annals of Indian Academy of Neurology and certain other journals and books. It is in the form of review articles, studies on etiology and treatment options, case reports and a couple of case control studies. This article brings together the rich data on sleep disorders available in the country in order to aid further research in the field.
The international classification of sleep disorders-2 (2005) (ICSD-2) classifies the sleep disorders in six major categories:[1]
I. Insomnia II. Sleep related breathing disorders III. Hypersomnias IV. Circadian rhythm sleep disorder V. Parasomnia VI. Sleep related movement disorders
We have tried to classify the available data according to these broad categories along with another category for those articles which could not fit into any of the above sections.
INSOMNIA
Insomnia refers to the difficulty in initiation, maintenance, duration or quality of sleep. People may experience poor concentration, lower productivity and poorer work quality as a result of insomnia.
Studies highlighting novel pharmacological agents for treating this disorder included the one on Ramelteon a novel MT1 and MT2 melatonin receptor selective agonist recently approved for the treatment of insomnia characterized by difficulty in sleep onset. According to a study by Devi V and Shankar PK, so far there is no evidence of cognitive impairment, rebound insomnia, withdrawal effects or abuse potential with the use of Ramelteon.[2]
In another multi-centric comparative clinical trial done on 100 patients, Phadke S and Shetty Jyoti, found that Eszopiclone was effective and comparable to other treatment in improving the sleep parameters in patients suffering from insomnia with a better safety profile than Zopiclone, Zolpidem and Nitrazepam.[3] Also, an interesting case report by Bhat T, Pallikaleth SJ and Shah N showed the successful use of Zolpidem for treatment of an 18- month- old child suffering from primary insomnia.[4]
In an attempt to generate awareness and spread knowledge about sleep disorders encountered with various other general medical conditions in routine practice, a series of books on insomnia in various clinical setting and its treatment have been published. These books were mainly intended for distribution amongst general physicians, orthopedicians, neurologists, psychiatrists, chest physicians and other specialties. These books include the management of insomnia in pain, chronic obstructive pulmonary disease, diabetes mellitus, and cardiovascular diseases.[5-8]
SLEEP RELATED BREATHING DISORDERS
Sleep related breathing disorders include several potentially serious conditions that include primary snoring, Upper airway resistance syndrome (UARS), obstructive sleep apnea-hypopnea syndrome (OSAHS), central sleep apnea, asthma and chronic obstructive pulmonary disease.
An effort to identify potential perception for genetic and biochemical basis of risk factors of OSAS and related co- morbidities was made by Kant surya et al. in their study published in 2008.[9] Kanwar M.S, in a comparative study on upper airway resistance syndrome (UARS) and obstructive sleep apnoea (OSA), discovered that UARS is not a distinct syndrome. It is merely a part of the disease spectrum of OSAHS. There exists a group that has characteristics of both OSA and UARS. The spectrum of disease is Primary snorers (PS) à UARS à combined (OSA 1 UARS) à OSA à OSAHS. UARS patients were mostly non- obese with active life style as compared to OSA patients. Also they displayed poor sleep efficiency with more prolonged awakenings compared to OSA patients.[10]
In an unusual study, Ambar Chakravarthy describes his personal experience of systemic effects of late night sleep deprivation and non-restorative sleep - A common experience amongst doctors. Results of some simple self- experimentations have been mentioned to highlight the possible pathogenetic mechanisms.[11]
Due to the paucity of data on Indian children with sleep disordered breathing (SDB), a study to evaluate the common clinical presentation, etiological factors, radiological and polysomnographic features in these children presenting to a tertiary care hospital was carried out by Bhool Shikha et al.[12]
In an attempt to find an effective and easy screening method for OSA, Nag Saikat et al. used the measurement of cephalic shadow to predict obstructive sleep apnoea, but found that there was no statistically significantly co- relationship with apnea-hypopnea index (AHI) and any of the cephalometric measurements.[13] In a case control study on OSA, Pradeep Kumar VG et al. found that patients with OSA had significantly higher BMI and ESS score, and were more likely to have hypertension and road traffic accidents.[14] The frequency, clinical and polysomnographic profile of sleep apnea syndromes seen in neurologic practice was studied by Kaul S, Meena AK and Murthy JM. According to their experience, obstructive apnea is the commonest sleep apnea in India and occurs predominantly in middle aged males.[15]
Zarir F. Udwadia et al. in a first-of-its-kind two-phase cross-sectional prevalence study found that the prevalence of SDB was 19.5%, and that of OSAHS was 7.5% in healthy urban Indian males between 35-65 years of age. The findings of this study and the high prevalence rates in middle-aged urban Indian men might have important public health implications in a developing country with limited health resources.[16] Suri J.C. and Sen M.K. studied the pulmonary functions in obstructive sleep apnoea hypopnoea syndrome in 89 patients attending the sleep centre of a tertiary care hospital.[17] Aggarwal Manju et al. in a study on maternal and fetal outcomes of sleep disordered breathing (SDB) in pregnancy concluded that SDB has widespread systemic effects that include adverse impact on maternal and fetal outcomes of pregnancy.[18]
Bhattacharya D. et al. presented a child with Pierre Robin Syndrome (PRS) - A rare genetic disorder characterized by micrognathia, cleft palate and glossoptosis; in whom sleep study performed showed presence of significant sleep disordered breathing. It also showed the effects of SDBs on physical and mental development.[19] Gangurde Aniket, Gothi D, Joshi JM in 2006 reported a case of a 13-year-old girl with postaxial acrofacial dysostosis (POADS) also called Miller Syndrome with sleep disordered breathing due to b i l a t e r a l t e m p o ro m a n d i b u l a r j o i n t ( T M J ) a n k y l o s i s a n d micrognathia/retrognathia, which was effectively treated with surgical correction.[20]
Jayan B et al. observed short term therapeutic efficacy of oral appliances both clinically and by PSG studies. According to them, Oral appliances therapy for OSA is non invasive, cost effective and beneficial to affected patients if desired efficacy is achieved. It greatly improves quality of life and cardio pulmonary health.[21] In another pilot study to evaluate the therapeutic efficacy of Thornton adjustable positioner (TAP), a titratable MAD (mandibular advancement appliances) in severe adult OSA cases, Jayan B et al. concluded that factoring predictable cephalometric measurements, BMId #30 kg/m2, and mandibular protrusion of 70%; severe OSA can be effectively managed with TAP.[22]
Suri J.C., Sen M.K. and Ojha U.C. studied the acceptance and compliance issues of Nasal cpap amongst Indian patients of obstructive sleep apnoea. Several factors responsible for non acceptance and poor compliance were identified, which included causes related to social, economic, cultural and geographical parameters peculiar to our country. [23] Another recently developed technique of Distraction osteogenesis has been found to be valuable and gives us the ability to both prevent and correct the development of sleep disordered breathing as found by Chowdhury S.K. Roy et al. in a study done in 2007.[24]
HYPERSOMNIA
Excessive daytime sleepiness, defined as sleepiness that interferes with daytime activities, productivity or enjoyment is usually abnormal and may reflect insufficient sleep, disrupted sleep or a primary sleep disorder such as narcolepsy.
Bhatia M and Arif MA reported probably the first documented case of narcolepsy, from India, diagnosed on the basis of clinical history and sleep studies in 2009.[25] Anjan Boral and Nilesh Shah have reported a case of Klein Levine Syndrome in 1994.[26] D.N Mendhekar et al. reported two cases of Kleine Levin Syndrome in 2001.[27] John DJ et al. presented a case in 2007, that highlights the clinical presentation, diagnostic criteria and treatment modalities of primary hypersomnia condition.[28] Bihari S. and Ramakrishnan N reported the case of a boy with episodic hyper somnolence. [29] Chittaranjan Andrade studied the response to fluoxetine and methylphenidate in primary hypersomnia.[30]
CIRCADIAN RHYTHM SLEEP DISORDERS
Circadian rhythm sleep disorders include the sleep disorders in which sleep- wake cycle is disturbed as it happens in workers having shift duties and in travelers who get a jetlag.
The pattern of sleep, prevalence of anxiety and depression and the overall impact of the nature of their employment on their lifestyle were studied in a segment of BPO workers employed in the call centers around New Delhi by Suri J.C. et al. in 2007. It was found that Circadian rhythm sleep disorders (CRSD) are not infrequently seen amongst shift workers who, in turn, comprise a large segment of the population employed in the BPO industry.[31]
PARASOMNIA
Parasomnia is an undesirable nondeliberate motor or subjective phenomenon that takes place during transition from wakefulness to sleep or during arousal from sleep.
Probably the first ever study in India on sleep paralysis was conducted by Jaswant Singh Neki in the year 1961. [32] Bharadwaj R and Kumar S presented two cases of somnambulism that highlight the importance of the diagnosis and treatment of this condition.[33] Rajesh, et al. with the help of a case- report of a 30 year old male patient had highlighted the fact that the onset of sleep walking in adult life which is most unusual suggests the presence of secondary causes rather than a primary sleep disorder; as in this case where the episodes of sleep walking were possibly due to nocturnal temporal lobe epilepsy.[34] Sawant NS et al. reported the case of a patient with isolated sleep paralysis who progressed from mild to severe sleep paralysis over eight years. He also restarted drinking alcohol to be able to fall asleep and allay his anxiety symptoms. The patient was taught relaxation techniques and he showed complete remission of the symptoms of SP on follow-up after eight months.[35]
SLEEP RELATED MOVEMENT DISORDERS
A variety of involuntary movements occur during the sleep and these are covered under this category of sleep related movement disorders.
Periodic limb movement disorder (PLMD) is one of the commonest neurological disorders and causes significant disability, if left untreated. However, it is rarely diagnosed in clinical practice, probably due to lack of awareness and/or lack of necessary diagnostic facilities. Restless leg syndrome (RLS), aging, pregnancy, uremia, iron deficiency, polyneuropathy are some of the common causes of secondary PLMD. Clinical presentation, polysomnographic findings and management of six patients of PLMD have been discussed by Dhanuka AK and Singh G.[36] Restless legs syndrome (RLS) is a disorder of motor activity with a circadian pattern, occurring frequently in patients with Parkinson's disease (PD). Krishnan PR, Bhatia M and Behari M attempted to estimate the prevalence of RLS in Indian PD patients and found that RLS is more common among patients with PD than controls.[37] Restless- legs syndrome and periodic leg movements in sleep are sleep-related limb movement disorders that often disrupt nocturnal sleep and cause excessive daytime sleepiness. The article by Samavedam A. and Krishna reviews the recent literature regarding epidemiology, etiology, pathogenesis, clinical features, differential diagnosis and management.[38]
OTHER RELATED ARTICLES
Indian literature also has a variety of case reports and studies which are related to sleep and sleep disorders.
Bhargav S.C. and Sethi S in their study evaluating 32 children suffering from Attention Deficit Hyperkinetic Disorder (ADHD) and their 20 healthy siblings inferred that sleep-related problems may have a significant bearing on the course and management of ADHD and that a careful evaluation of sleep history is recommended in these children.[39]
A study by Suri J.C., et al. was done to analyze the epidemiology of sleep disorders in the elderly population. This exhaustive study included 1240 grand-parents of school-going children in Delhi.[40] Also, Suri J.C., et al. using the Chervin and the Stanford Sleep Clinic questionnaire had conducted a study on a sample of adult population of Delhi which reflected that the impact of sleep disorders on the morbidity profile on this strata of society, the phenomenal burden of undiagnosed sleep disorders and its impact on social, mental, physical and economic health of the society. [41] Another questionnaire based survey by Suri J.C., et al. was performed to determine the prevalence of sleep related disorders in Indian school-going children residing in Delhi. It was of great concern that the findings suggested that no effort was made on the part of parents to seek medical help in significantly large number of children in whom sleep disorders were present, indicating a total lack of awareness amongst the general population about the larger implications of sleep disorders in children.[42] Narendhran R, et al. designed a study to assess the psychometric properties of a parent-rated measure of sleep habits i.e. Children Sleep Habits Questionnaire (CSHQ) in Indian school going children, concluding that CSHQ is a reliable and internally consistent scale, and it is useful optional tool for assessing sleep problems in Indian school children.[43]
A study was conducted by Ghoshal A.G., et al. in the Department of Respiratory Medicine, Nil Ratan Sircar Medical College, Kolkata over a period of two years on 120 uncomplicated stable adult asthmatics to assess the incidence of Excessive Daytime Sleepiness (EDS) in patients with asthma, and to find out its correlation with the severity and level of control of asthma. A definite correlation was found between EDS with the severity of asthma and the level of control but not with the mode of diagnosis of asthma.[44]
One study by Krishna Pushpa, Shwetha S on 67 medical students aimed to analyze the quality of sleep in medical students using the Pittsburgh Sleep Quality Index and to relate sleep with blood pressure (BP), body mass index (BMI) and academic performance. This study shows the high prevalence of poor sleep quality and underlined the close relationship of sleep with BP, BMI and academic performance among medical students.[45] Meshram Sushant H et al. after having conducted a questionnaire-based study to assess the behavior, attitude and knowledge of sleep medicine among resident doctors had concluded that there was an intense need for including sleep medicine in their curriculum.[46]
Based on a comparative hospital study based on electroencephalographic and radiological profiles of the subjects, by Goel D, et al., it was found that it is likely that dominant side and frontal lobe involvement in symptomatic epilepsies is associated with higher number of seizures during sleep and that techniques like sleep EEG, sleep deprived EEG and video-EEG telemetry are supposed to improve outcome in the diagnosis of patients with sleep seizures. Study on clinical, electroencephalographic and radiological profile.[47] by Bhatia M, et al. aimed to translate the Epworth Sleepiness Scale into Hindi and validate it for use in the Hindi speaking population in India. With the help of a study conducted by them the Hindi version was found to be valid and reliable for use in the evaluation of sleepiness in Hindi speaking population of our country.[48]
S. R. Iyer and R. R. Iyer in their article, 'Sleep and Ageing - Interactions and Consequences' have described sleep patterns changing subjectively and polysomnographically with ageing.[49] In yet another article they describe the existence of a close and interesting relationship amongst sleep, OSA, obesity, insulin resistance and metabolic syndrome.[50]
A case report on electrical Status Epilepticus of Sleep was authored by Nilesh Shah and Kedar Kale.[51] Mahesh Bhirud and Nilesh Shah in 2004 presented a case-reports of Clozapine induced urinary incontinence during sleep which were treated with imipramine.[52] The handbook of sleep, authored by Dr. Nilesh Shah, et al. provides a comprehensive information on sleep and the various therapies recommended for sleep and is a handy reference for clinicians, helping them tackle the challenges of the increasing incidence of insomnia in the general population.[53]
REFERENCES
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(Lenbrook Division), Abbott India Ltd; 2005. 9. Kant S, Dixit S, Dubey A, Tewari S. Obstructive sleep apnoea syndrome: genetic and biochemical perspective. Indian J Sleep Med 2008;3:ISSN 0973-340X. 10. Kanwar MS. Coexisting UARS and OSA. Indian J Sleep Med 2008;3:ISSN 0973-340X. 11. Chakravarthy A. My non-restorative sleep syndrome. Ann Indian Acad Neurol 2000;3:69- 72. 12. Bhool S, Suri JC, Sen MK, Venkatachalam VP. Clinical, radiological and polysomnographic evaluation of sleep disordered breathing in children. Indian J Sleep Med 2008;3:ISSN 0973-340X. 13. Nag S, Bardhan S, Saha I, Dey R, Paul R, Acharyya Di, et al. Can measurement of cephalic shadow predict obstructive sleep apnoea - Result of an analysis. Indian J Sleep Med 2007;2:ISSN 0973-340X. 14. Pradeep Kumar VG, Bhatia M, Tripathi M, Srivastava AK, Jain S. Obstructive sleep apnea: a case-control study. Neurol India 2003;51:497-9. 15. Kaul S, Meena AK, Murthy JM. Sleep apnea syndromes: clinical and polysomnographic study. Neurol India 2001;49:47-50. 16. Udwadia ZF, Doshi AV, Lonkar SG, Singh CI. Prevalence of sleep- disordered breathing and sleep apnoea in middle-aged urban Indian men. Am J Respir Crit Care Med 2004;169:168- 73. 17. Suri JC, Sen MK. Pulmonary functions in obstructive sleep apnoea hypopnoea syndrome in a cohort of patients attending the sleep centre of a tertiary care hospital. Indian J Sleep Med 2007;2:ISSN 0973-340X. 18. Aggarwal M, Suri JC, Suri S, Sen MK. Maternal and Fetal outcomes of sleep disordered breathing in pregnancy. Indian J Sleep Med 2008;3:ISSN 0973-340X. 19. Bhattacharya D, Chakrabarti S, Sen MK, Gupta N. Study of sleep disordered breathing in a child with Pierre robin syndrome. Indian J Sleep Med 2008;3:ISSN 0973-340X. 20. Gangurde A, Gothi D, Joshi JM. Sleep apnoea in postaxial acrofacial dysostosis (Miller) syndrome. Indian J Sleep Med 2006;1: Page no missing ??? 21. Jayan B, Prasad BN, Rajput AK, Bhattacharya R, Dhiman RK, Thampi PS. Management of obstructive sleep apnoea with oral appliances: Our experience. Indian J Sleep Med 2006;1:ISSN 0973-340X. 22. Jayan B, Prasad NB, Kamat UR, Khara OP, Bhattacharya D. Therapeutic efficacy of thornton adjustable positioned in the management of patients with severe obstructive sleep apnoea: A pilot study. Indian J Sleep Med 2008;3:ISSN 0973-340X. 23. Suri JC, Sen MK, Ojha UC. Acceptance and compliance issues of nasal cpap amongst Indian patients of obstructive sleep apnea. Indian J Sleep Med 2006;1:ISSN 0973-340X. 24. Chowdhury SK, Roy, Jayan B, Menon PS, Prasad BN, Ravishankar K. Management of obstructive sleep apnoea and non apnoeic snoring with maxillo-mandibular distraction osteogenesis. Indian J Sleep Med 2007;2:ISSN 0973-340X. 25. Bhatia M, Arif MA. Narcolepsy an often missed diagnosis: First documented case from India. Neurol India 2009;57:509-11. 26. Baral A, Shah N. Klein Levine Syndrome: A Case Report. J Indian Med Assoc 1994;92:273-4. 27. Mendhekar DN, Jiloha RC, Gupta D. Kleine levin syndrome: a report of two cases. Ind J Psychiatry 2001;43:276-8. 28. John DJ, Manoharan A, Varghese R. A case of primary hypersomnia. Ann Indian Acad Neurol 2007;10:58-60. 29. Bihari S, Ramakrishnan N. A boy with episodic hyper somnolence-A case report. Indian J Sleep Med 2007;2:ISSN 0973-340X. 30. Chittaranjan A. Primary hypersomnia: response to fluoxetine and methylphenidate. Indian J Psychiatry 1999;41:377-80. 31. Suri JC, Sen MK, Singh P, Kumar R, Aggarwal P. Sleep patterns and their impact on lifestyle, anxiety and depression in BPO workers. Indian J Sleep Med 2007;2:ISSN 0973-340X. 32. Singh JN. Observations on sleep-paralysis. Indian J Psychiatry 1961;3:160-9. 33. Bharadwaj R, Kumar S. Somnambulism: diagnosis and treatment. Indian J Psychiatry 2007;49:123-5. 34. Rajesh S, Durairaj R, Mugundan K, Rajasekar M, Balasubramanian S, Gobinathan S, et al. Somnambulism due to temporal lobe epilepsy - a case report. Ann Indian Acad Neurol 2004;7:437-8. 35. Sawant NS, Parkar SR, Tambe R. Isolated sleep paralysis. Indian J Psychiatry 2005;47:238- 40. 36. Dhanuka AK, Singh G. Periodic limb movement disorder: a clinical and polysomnographic study. Neurol India 2001;49:366-70. 37. Krishnan PR, Bhatia M, Behari M. Restless legs syndrome in Parkinson's disease: a case- controlled study. Mov Disord 2003;18:181-5. 38. Samavedam A, Krishna. Sleep related leg movement disorders. Indian J Sleep Med 2006;1:0973-340X. 39. Bhargava SC, Sethi S. Sleep disorders in children with attention-deficit hyperactivity disorder. Indian J Psychiatry 2005;47:113-5. 40. Suri JC, Sen MK, Ojha UC, Adhikari T. Epidemiology of sleep disorders in the elderly - a questionnaire survey. Indian J Sleep Med 2009;4:0973-340X. 41. Suri JC, Sen MK, Adhikari T. Epidemiology of sleep disorders in the adult population of Delhi - A questionnaire based study. Indian J Sleep Med 2008;3:0973-340X. 42. Suri JC, Sen MK, Adhikari T. Epidemiology of sleep disorders in the school children of Delhi - A questionnaire based study. Indian J Sleep Med 2008;3:0973-340X. 43. Narendhran R, Bharti B, Malhi P. Children Sleep Habits Questionnaire (CSHQ): Psychometric validation in Indian school children. Indian J Sleep Med 2008;3:0973-340X. 44. Ghoshal AG, Sarkar S, Mondal P, Bhattacharjee SK, Shamim S, Mundle M. A study of excessive daytime sleepiness in asthma. Indian J Sleep Med 2008;3:0973-340X. 45. Krishna P, Shwetha S. Sleep quality and correlates of sleep among medical students. Indian J Sleep Med 2008;3:0973-340X. 46. Meshram SH, Meshram CS, Mishra GS, Bharshankar R. Behaviour, attitude and knowledge of sleep medicine among resident doctors in university hospitals of Central India: A questionnaire based study. Indian J Sleep Med 2007;2:ISSN 0973-340X. 47. Goel D, Mittal M, Bansal KK, Srivastav RK, Singhal A. Sleep seizures versus wake seizures: A comparative hospital study on clinical, electro-encephalographic and radiological profile. Neurol India 2008;56:151-5. 48. Bhatia M, Prasad K, Pande RN. Hindi version of epworth sleepiness scale: a validity study. Indian J Sleep Med 2006;1:ISSN 0973-340X. 49. Iyer SR, Iyer RR. Sleep and ageing - interactions and consequences. Indian J Sleep Med 2008;3:ISSN 0973-340X. 50. Iyer SR, Iyer RR. Sleep and obesity in the causation of metabolic syndrome. Int J Diab Dev Ctries 2006;26:63-9. 51. Shah N, Kale K. Electrical status epilepticus of sleep - a case report. Arch Indian Psychiatry 1998;4:114-5. 52. Bhirud M, Shah N. Clozapine induced urinary incontinence during sleep. Indian J Psychiatry 2004;46:280. 53. Shah N, Gandhi A, Pandit P. The handbook of Sleep. Mumbai: Lenbrook, BASF Pharma Publication; 2000.
Nilesh Shah Abha Bang Aparna Bhagat Department of Psychiatry L. T. M. Medical College and General Hospital Sion, Mumbai - 400 022, India 41 Sexuality research in India: An update
Om Prakash, T. S. Sathyanarayana Rao
ABSTRACT
This review provides the available evidence on sexual dysfunctions in India. Most of the studies have concentrated on male sexual dysfunction and hardly a few have voiced the sexual problems in females. Erectile dysfunction (ED), premature ejaculation (PME) and combinations of ED and PME appear to be main dysfunctions reported in males. Dhat syndrome remains an important diagnosis reported in studies from North India. There is a paucity of literature on management issues with an emergent need to conduct systematic studies in this neglected area so that the concerns of these patients can be properly dealt with.
Key words: Dhat syndrome, female sexual dysfunction, India, male sexual dysfunction
INTRODUCTION
Human sexuality is inherently related to some of the social and public health problems in India. These problems may involve contraceptive use, child abuse, sex education, legal issues of homosexuality and AIDS. These health problems have a significant impact on existing health infrastructure and budget. These problems also need to look within the context of poverty, stressful living situations, diverse cultural belief systems, quackery, ignorance and inadequate health services. However, there is little recognition of how these health problems are related to human sexuality and their dysfunctions. There is a need to understand how sexual attitudes, beliefs, and values act and influence these problems. Our cultural perspective can also shape the experience and understanding of these disorders.[1] There is a need to research sexual experiences and dysfunctions, which further influence adult behavior patterns in India.
In this review, our aim is to present sexual dysfunction from the Indian perspective. Available data, based clinical studies from India, are reviewed and important findings highlighted. Our presentation is limited to sexual dysfunction only and paraphilias will be not discussed.
Sexual dysfunction in males
One of the first literatures in male sexual dysfunctions was reported by Bagadia et al. (1959).[2] They observed ignorance, superstitions, fears and guilt feelings about sex as major areas of concern, and developed a method of educational group therapy for minor sex disorders, which involved a psycho- education including anatomy, physiology and mind-body continuum related to sexual disorders.
Bagadia and his colleagues (1972)[3] studied 258 male out- patients of teaching hospital setting with sexual problems as main concerns. They found anxiety over nocturnal emission (65%) and passing semen in urine (47%) main problems in the unmarried group; while impotence (48%), premature ejaculation (34%) and passing semen in urine (47%) were common in married group. Anxiety state (57%), schizophrenia (16%) and reactive depression (16%) were common psychiatric diagnosable conditions in that sample.
Nakra and his colleagues (1977)[4] studied sexual disorders in 150 males attending psychiatric unit of a teaching general hospital. They reported that 9.2% of all patients seen had potency disorders. The commonest psychosexual disorders were impotence (acute onset 11.3%; insidious onset 24%), premature ejaculation (PME) (acute onset 10%; insidious onset 15.3%), Dhat syndrome (with impotence/PME 10.7%; without 10%) and apprehension about potency (18%). The wives of these patients showed either helpful or indifferent attitudes towards the problem of sexual dysfunction. The authors also concluded that PME is a state of hyper-sexual arousal.
Using the same cohort, Nakra and his colleagues (1978)[5] found that nearly 75% of the patients had practiced masturbation before developing potency disorders and nearly 43% had guilt associated with masturbation. The authors also found nocturnal emission and adolescent homosexual contacts in 95% and 16% of the subjects respectively and of these 69% and 39% respectively had associated guilt feelings. 64% of the subjects considered loss of semen harmful to health.
Kar and Verma (1978)[6] studied the sexual lives of 72 married psychiatric patients and compared with 80 married relatives or friends from same socio- cultural background. With regard to marriage, 63% of subjects with schizophrenia and 24% of manic-depressives were married after the onset of the illness; 48.5% of the patients failed to perform sexually on suhag raat (first honeymoon night after marriage) compared with 18.7% of the controls faced same problem. Premature ejaculation was reported in 48% of subjects in 'patient group' and 40% in controls. Erectile impotence was reported in 27% and 13% in 'patient group' and 'control group' respectively. 63.4% subjects from 'patient group' described their sexual relationship unpleasant as compared to only 2.5% from 'control group' considered unpleasant.
Kumar and his colleagues (1983)[6] conducted a study on 40 married male neurotics and 22 healthy controls from teaching hospital setting. They found that the sexual behavior of the neurotics was similar to healthy controls before the onset of illness. There was a significant decrease in the frequency of coitus, sexual satisfaction of self, perceived sexual satisfaction of the spouse and sexual adequacy.
Bagadia and his colleagues (1983)[7] used behavioral techniques to treat 26 married males with PME and secondary impotence; 58% patients improved with those techniques. Gupta and her colleagues (1989)[8] described the application of Modified Masters and Johnson technique in the treatment of sexual inadequacy in 21 married males. 76.2% patients showed improvement after this technique.
Avasthi and his colleagues (1994)[9] conducted an outcome study of 66 male patients with psychosexual dysfunction in the context of socio-demographic and clinical variables. Short term outcome (of one year duration) and long term outcome (of seven years' duration) of those patients were recorded. Erectile dysfunction (ED), PME, and combination of ED and PME were reported by 30, 12 and 45% of subjects respectively. Dhat syndrome, with ED/PME, was reported by 9% of the subjects. Nearly 38% of the patients dropped out of the treatment ('drop-out group'). At one year follow-up, nearly 44% of the patients perceived improvement ('improved at one year group'), while rest did not ('no change at one year group'). At the end of seven years, nearly 70% of the original 66 patients could be recontacted. Significantly, a greater number of subjects from the 'drop-out group' had active sexual dysfunction than other two groups. The study proved that improvement in the short-term outcome indicated favorable long-term outcome.
Verma and his colleagues (1998)[10] analyzed data on 1000 consecutive patients with sexual disorders attending the psychosexual clinic at the tertiary care setting. They found premature ejaculation (77.6%) and nocturnal emission (71.3%) frequent problems followed by a feeling of guilt about masturbation (33.4%), small size of the penis (30%) and erectile dysfunction (23.6%). Excessive worry about nocturnal emission, abnormal sensations in the genitals, and venereophobia was reported in 19.5, 13.6, and 13% of patients, respectively. A file review of 178 male patients with sexual dysfunction by Avasthi and his colleagues (2003)[11] revealed that high income, married status, presence of partner at evaluation, and liberal attitude towards sexuality increased the chances of selection of behavioral sex therapy. The outcome of therapy was associated with treatment adherence. Participation of the spouse resulted in lower dropout rates.
Gupta and his colleagues (2004)[12] attempted to assess clinical profiles of 150 patients attending skin OPD for psychosexual problems. Among them, erectile dysfunction (34%) was the commonest problem, followed by premature ejaculation (16.6%), Dhat syndrome (15.3%), and nocturnal emission (14%).
Kendurkar and his colleagues (2008)[13] assessed the pattern of sexual dysfunction in the patients attending a marriage and sex clinic from 1979 to 2005 by looking into their medical records. After reviewing the data of 1242 patients, they found premature ejaculation being the most common complaint and the most commonly diagnosed clinical entity, followed by male erectile problems and Dhat syndrome.
Sexual dysfunction in females
As compared to male sexual dysfunction, a few Indian studies are available in the area of female sexual dysfunction. This area remains largely unexplored. Agarwal (1977)[14] reported a study of 17 female cases of frigidity. All except one presented with neurotic or somatic symptoms. Frigidity was associated with ignorance regarding sexual activity, fear of pregnancy, marital disharmony, lack of emotional atmosphere, tiredness and poor precoital attention. Superficial psychotherapy and guidance helped 65% of the subjects with frigidity.
In the review by Kulhara and Avasthi (1995),[15] there was mention of one unpublished study from Chandigarh which documented 13 female patients out of 464 attenders of a special clinic dealing with marital and sexual dysfunctions. Vaginismus, dyspareunia and lack of sexual desire were the main problems reported.
Kar and Koola (2007)[16] conducted a postal survey among English-speaking persons from a south Indian town and found orgasmic difficulties in 28.6% females. Moreover, almost 40% of females reported to have never masturbated.
In the study among 100 consecutive women attending the Department of Pediatrics for the care of non-critical children in a tertiary care teaching hospital, Avasthi and his colleagues (2008),[17] found 17% of the subjects encountered one or more difficulties during sexual activities. These difficulties were in the form of headache after sexual activity (10%), difficulty reaching orgasm (9%), painful intercourse (7%), lack of vaginal lubrication (5%), vaginal tightness (5%), bleeding after intercourse (3%) and vaginal infection (2%). 14% subjects attributed these difficulties to their own health problems; further lack of privacy (8%), spouse's health problems (4%) and conflict with spouse (4%) were the other cited reasons for those difficulties. None considered their sexual difficulty significant enough to demand a thorough clinical assessment.
In another cross-sectional survey of 149 married women in a medical outpatient clinic of a tertiary care hospital, Singh and his colleagues (2009),[18] reported female sexual dysfunction (FSD) in 73.2% subjects of the sample. The complaints elicited were difficulties with desire in 77.2%, arousal in 91.3%, lubrication in 96.6%, orgasm in 86.6%, satisfaction in 81.2%, and pain in 64.4% of the subjects. Age above 40 years and fewer years of education were identified as contributory factors. Women attributed FSD to physical illness in participant or partner, relationship problems, and cultural taboos but none had sought professional help.
Dhat syndrome
Studies pertaining to Dhat syndrome, a culture bound syndrome, have mostly defined clinical features. This "semen loss"-related psychological distress has been extensively reviewed by Prakash (2007),[1] and Avasthi and Jhirwal (2005). [19] The important studies conducted in this area were done by Malhotra and Wig (1975),[20] Behere and Natraj (1984),[21] Singh (1985), Chadda and Ahuja (1990),[22] Bhatia and Malik (1991),[23] Perme et al. (2005),[24] and Dhikav et al. (2007).[25]
Wig (1960),[26] coined the term "Dhat syndrome," characterized by vague somatic symptoms and guilt attributed to semen loss through nocturnal emissions, urine and masturbation though there is no evidence of loss of semen.
Behere and Natraj (1984)[21] and Bhatia and Malik (1991)[23] found that the patients with symptoms of Dhat syndrome were mostly young, recently married, poor, rural and from family with conservative attitudes towards sex. Most studies found that these patients lose their semen in sleep, with urine, masturbation, hetero/homosexual sex.
Most studies found erectile dysfunction (22-62%) and premature ejaculation (22-44%) as commonly associated psychosexual dysfunctions, while depressive neurosis (40-42%), anxiety neurosis (21-38%), somatoform/hypochondriasis (32-40%) as the most reported psychiatric disorders in patients diagnosed with Dhat syndrome.
Chadda and Ahuja (1990) could not find any abnormality on urine examination except oxaluria (10%) and phosphaturia (6%). On follow-up of these patients, Behere and Natraj (1984) found that majority of the patients recovered (66%), while the rest either improved (22%) or were unchanged (12%).
Behere and Natraj (1984)[21] and Bhatia and Malik (1991) [23] explored the patients' beliefs regarding composition of Dhat; found majority believe semen, followed by pus, sugar, concentrated urine, infection or "not sure." Majority considered masturbation and/or excessive indulgence in sexual activities as important causative factor, followed by venereal diseases, urinary tract infections, overeating, constipation or worm infestation, disturbed sleep or genetic factors.
Regarding management of Dhat syndrome, Wig (1960)[26] suggested emphatic listening, reassurance and correction of erroneous beliefs. Avasthi and Gupta (1997),[27] in their manual proposed that the management of Dhat syndrome involves sex education, relaxation therapy and medications.
Prakash and Meena (2007),[28] provided an explanation regarding this belief derived from the anatomy and physiology of penis. They proposed that patients with Dhat syndrome believe that whatever blood is collected in cavernous spaces during erection, probably converts into semen. Hence, with every sexual activity they lose blood; as blood is their source of energy, they lose energy everyday becoming more weak and lethargic.
Chadda and Ahuja (1990)[22] advocated psycho-education and culturally informed cognitive behavioral therapy. Bhatia and Malik (1991)[23] found anti-anxiety and antidepressant drugs better as compared to psychotherapy. Dhikav and his colleagues (2008)[25] advocated selective serotonin reuptake inhibitors along with regular counseling.
CONCLUSION
This review highlights the available evidence in the field of psychosexual medicine in India. It is important to mention that all studies were from a hospital setting and none from community. Only a few studies explored female sexual dysfunction. Very few studies spoke about management issues. Dhat syndrome could be an important diagnostic entity to be researched. There is a strong need to perform studies in these areas. REFERENCES
1. Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10. 2. Bagadia VN, Vardhachari KS, Mehta BC, Vahia NS. Educational group psychotherapy for certain minor sex disorders of males. Indian J Psychiatry 1959;1:237-40. 3. Bagadia VN, Dave KP, Pradhan PV, Shah LP. Study of 258 male patients with sexual problems. Indian J Psychiatry 1972;14:143-51. 4. Nakra BR, Wig NN, Varma VK. A study of male potency disorders. Indian J Psychiatry 1977;19:13-8. 5. Nakra BR, Wig NN, Varma VK. Sexual behavior in the adult north Indian patients of male potency disorders. Indian J Psychiatry 1978;20:178- 82. 6. Kar GC, Varma LP. Sexual problems of married male patients. Indian J Psychiatry 1978;20:365-70. 7. Bagadia VN, Ayyar KS, Dhawale KM, Pradhan PV. Treatment of 26 cases of male sexual dysfunction by behaviour modification techniques. Indian J Psychiatry 1983;25:29-33. 8. Gupta P, Banerjee G, Nandi DN. Modified Masters Johnson Technique in the treatment of sexual inadequacy in males. Indian J Psychiatry 1989;31:63-9. 9. Avasthi A, Basu D, Kulhara P, Banerjee ST. Psychosexual dysfunction in Indian male patients: revisited after seven years. Arch Sex Behav 1994;23:685-95. 10. Verma KK, Khaitan BK, Singh OP. The frequency of sexual dysfunctions in patients attending a sex therapy clinic in North India. Arch Sex Behav 1998;27:309-14. 11. Avasthi A, Sharan P, Nehra R. Practicing behavioral sex therapy in India: Selection, modifications, outcome, and dropout. Sex Disabil 2003;21:107- 12. 12. Gupta SK, Dayal S, Jain VK, Kataria U, Relhan V. Profile of male patients with psychosexual disorders. Indian J Sex Trans Dis 2004;25:33-7. 13. Kendurkar A, Kaur B, Agarwal AK, Singh H, Agarwal V. Profile of adult patients attending a marriage and sex clinic in India. Int J Soc Psychiatry 2008;54:486-93. 14. Agarwal AK. Frigidity: A clinical study. Indian J Psychiatry 1977;19:31-7. 15. Kulhara P, Avasthi A. Sexual dysfunction on the Indian subcontinent. Int Rev Psychiatry 1995;7:231-9. 16. Kar N, Koola MM. A pilot survey of sexual functioning and preferences in a sample of English-speaking adults from a small south Indian town. J Sex Med 2007;4:1254-61. 17. Avasthi A, Kaur R, Prakash O, Banerjee A, Kumar L, Kulhara P. Sexual behavior of married young women: A preliminary study from north India. Indian J Community Med 2008;33:163-7. 18. Singh JC, Tharyan P, Kekre NS, Singh G, Gopalakrishnan G. Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India. J Postgrad Med 2009;55:113-20 19. Avasthi A, Jhirwal OP. The concept and epidemiology of Dhat syndrome. J Pak Psychiatr Soc 2005;2:6-8. 20. Malhotra HK, Wig NN. Dhat syndrome: A culture-bound sex neurosis of the orient. Arch Sex Behav 1975;4:519-28. 21. Behere PB, Natraj GS. Dhat syndrome: The phenomenology of a culture-bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8. 22. Chadda RK, Ahuja N. Dhat syndrome: A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9. 23. Bhatia MS, Malik SC. Dhat syndrome: A useful diagnostic entity in Indian culture. Br J Psychiatry 1991;159:691-5. 24. Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome: A functional somatic syndrome of the Indian subcontinent? Gen Hosp Psychiatry 2005;27:215-7. 25. Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4. 26. Wig NN. Problem of mental health in India. J Clin Social Psychiatry 1960;17:48-53. 27. Avasthi A, Gupta N. Manual for standardized management of single males with sexual disorders. Marital and Psychosexual Clinic: Chandigarh; 1997. 28. Prakash O, Meena K. Association between Dhat and loss of energy - A possible psychopathology and psychotherapy. Med Hypotheses 2008;70:898-9.
Om Prakash Department of Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS) Delhi - 110 095.
T. S. Sathyanarayana Rao Department of Psychiatry, JSS University, JSS Medical College Hospital, M.G. Road, Mysore - 570 004, India 42 Sexual variation in India: A view from the west
Gurvinder Kalra, Susham Gupta, Dinesh Bhugra
ABSTRACT
Sexual variation has been reported across cultures for millennia. Sexual variation deals with those facets of sexual behavior which are not necessarily pathological. It is any given culture that defines what is abnormal and what is deviant. In scriptures, literature and poetry in India same sex love has been described and explained in a number of ways. In this paper we highlight homosexual behavior and the role of hijras in the Indian society, among other variations. These are not mental illnesses and these individuals are not mentally ill. Hence the role of psychiatry and psychiatrists has to be re-evaluated. Attitudes of the society and the individual clinicians may stigmatize these individuals and their behavior patterns. Indian psychiatry in recent times has made some progress in this field in challenging attitudes, but more needs to be done in the 21st century. We review the evidence and the existing literature.
Key words: Bisexuality, hijra, homosexuality, men who have sex with men, sexual variation, sexual fluidity
INTRODUCTION
Sexual variation is sexual behavior which varies from the usual heterosexual intercourse; the behavior includes alternative sexual orientation such as homosexuality and bisexuality. Its description in various forums has been well known across the globe for millennia. A recent term, which has been used extensively, is 'Men who have Sex with Men' (MSM). Gender roles and gender role identities may fluctuate, as does the sexual behavior, depending upon the availability of sexual partners and opportunities.
Although the data on sexual variation are extremely limited, especially from India, in this paper we propose to highlight some of the conceptual issues. We aim to describe some of these behavior patterns in historical accounts and raise issues related to managing these in clinical settings.
Variation
In this paper, we focus on bisexuality and homosexuality. Sexual orientation refers to a person's preference for sexual and emotional relationships with a particular sex.[1] Sexuality is not just sexual, but also has an emotional component and impact. Sexual behavior should not be equated with sexuality. Societal attitudes influence this behavior and whether individuals carry these out openly or in secret. For bisexuality, the male role takes on a different dimension. In a patriarchal society such as India the roles of fathers, brothers and husbands may be threatened by variations in sexual behavior.
However, sex and gender are often confused. The sex of an individual is determined biologically, whereas gender may be influenced by social factors. Bullough[2] described societies as 'sex positive' or 'sex negative'. Sex positive societies celebrate sexual activity and the sexual act is seen as meant for pleasure, whereas the main function of sex in sex negative societies is seen as for procreation. In addition, a further complicating factor in individual sexual behavior is not only personality and orientation, but also whether they meet social expectations, which are likely to be affected by kinship and socio- centric traditions of the society they come from. India, by and large, remains a traditional socio-centric society rapidly moving to an ego-centric society as a result of urbanization, industrialization under the overall impact of globalization. In this paper we do not propose to cover other variations, such as pedophilia, but the aim is to focus on homosexuality and bisexuality. We will discuss the notion of hijras in India, their role in society and associated attitudes. Historically, psychiatry as a profession has placed itself in treating these conditions sometimes primitively and sometimes without adequate safeguards as agents of social control. However, in the West this approach has been discredited, though it continues in parts of the world, including India.
HISTORY
The attitudes to bisexuality and homosexuality in India have been ambivalent to say the least. From historical accounts, it appears that these types of behavior patterns were tolerated and celebrated. The dilemma for the modern day clinical practitioner in India is whether homosexuality (and which is often equated with homosexual behavior) is a Western concept and was imported into the country with the British Raj. Often this view is expressed by politicians on both ends of the political spectrum. Interestingly, it would appear that a large proportion of MSM in India are married, unlike in the West. Whether this reflects true bisexuality or simply homosexual desire subservient to socio-centric society needs to be explored further. These individuals are less likely to see themselves as homosexuals, even in large metropolises. Further, the advent of the internet and access to sexual partners through the web has meant that the attitude and behavior may be becoming more secretive, even in the younger generation.
Early Buddhist and Hindu periods covered in ancient texts such as Manusmriti, Arthashastra, and Kamasutra refer to same sex attraction and behavior. The Buddhist tradition, as indicated in the pillar caves of Karle (50-75 CE), shows two bare-breasted women embracing each other. In Hindu scriptures, for example, Bhagiratha is born from the union of two women. Shikhandi changes gender and Ardhnarishwar (half-man, half-woman) are described. Ayyappa (dual gendered god) is worshipped and honoured by hijras. Several sculptures and carvings in Khajuraho depict same sex behavior, including mutual fellatio and orgiastic scenes. The God Ayyappa was born of intercourse between Shiva and Vishnu when the latter temporarily assumed the form of a beautiful seductive woman-Mohini.[3] A number of 14th century texts in Sanskrit and Bengali (including Krittivasa Ramayana) narrate how King Bhagiratha was born of the union between two women blessed by Lord Shiva.[4]
Hijras in India have a degree of importance. They would come and dance in Hindu households at the times of marriage and when a male child is born. They often refer to themselves as those having no (sexual) desire for women. [5] They are differentiated clearly from effeminate or gay men in India. [6] Reddy (2005)[7] notes that, by virtue of their importance, the hijras are man- minus-man, but also man-plus-woman. They wear female attire, use make up, have feminine names and behave in a feminine manner-some more than the others. They may be born as hermaphrodites or castrated. [5] Various sociological studies[8-10] reveal that many people living in these organized hijra communities practice male homosexual prostitution. Some members of this community were found to be permanently attached to prosperous male homosexuals who took care of their financial needs.
In Persian and Sufi traditions, love of a man for another man is described, although it can be argued that it is mortal man loving god. Muslim presence in India raised the notion of poetry in the form of love songs-ghazals and the concept of one male's love for another. Gupta (2008) [11] argues that in Baburnama, the Mughal Emperor Babur is quite clear about his indifferent love for his wife and his preference for a young man. It is quite possible that such attachments were those of a mentor and guide in an emotional sense rather than a sexual one. Many paintings and works of fiction dating from several centuries depict same sex love and loss. For example, in Siraj Aurangabadi's poem Bustani-i-Khayal the narrator, heart broken over the loss of his (male) beloved, seeks solace in the company of courtesans who cheer him up.[12] Many poets used feminine pen names to hide their true desire in response to British Victorian attitudes to homosexuality. Although selective, the brief review indicates that same sex relationships, whether emotional attachments or sexual, have been around in India for a considerable period of time and are not an import from the West. Recent studies by several authors such as Vanita and Kidwai[4] confirm these.
ATTITUDES
There is little doubt that negative societal attitude to homosexuality has contributed to medicalization of the variation leading to often inappropriate interventions. Foucault (1988, 1990)[13] saw this control as another form of social control over an individual's sexual expression. He notes that this is not dissimilar to canonical law and points out that any treatment should be looked through the lens of human rights.
Homosexuality was removed from the Diagnostic and Statistical Manual in the 1970s and in the other diagnostic system ICD-10- only ego dystonic homosexuality is included. The British made male homosexual behavior illegal and it is rather ironic that 62 years after independence archaic colonial laws such as Section 377 of the Indian penal code still exist. Although the Delhi High Court has termed the Act illegal, pending appeals to the Supreme Court make its total repeal and amendment to the law delayed. It is also interesting that male homosexual behavior is illegal, but not the female one. In spite of the evidence to the contrary and appeals by various eminent Indians, including the Nobel prize winner Professor Amartya Sen, and the fact that the same law was repealed in Britain in 1967, India remains at par with countries such as Zimbabwe! Attitudes to male homosexuality are often negative, especially because in patriarchal societies heterosexual males may feel threatened. These are negative because of extra-marital affairs being seen as sinful and dirty. Furthermore, quite wrongly, homosexual behavior is equated with pedophilia, which is seen as a form of recruitment into homosexuality.
Implications of attitudes
Thus these negative attitudes are influenced by legal factors and stigma related to 'non-standard' sexual behavior. As is evidenced from several countries in Africa, some politicians believe that homosexual behavior is single handedly responsible for the spread of HIV infections and AIDS, thereby denying potentially life-saving medications and preventive education. In addition, religious dogma is often brought in to emphasize the notion of 'the other', thus creating a further sense of alienation. What is surprising is how attitudes to female homosexual behavior vary from those towards males. Female same-sex activity is seen as arousing by the males. Bisexual individuals are often accused of 'sitting on the fence' or 'being unable to make their mind up' or 'having the best of both worlds'. It is also likely that measurement of sexual orientation is often rather vague and uncertain. Kinsey (1948)[14] developed his scale and used it on a large number of people; the questions focused on whether individuals saw themselves as predominantly homosexual or heterosexual. However, no distinction is made between same sex or opposite sex fantasy, arousal or behavior. Klein's grid test (1993)[15] measures a person's sexual orientation on a continuum between straight and gay giving a more subtle and nuanced measurement of sexual identity. However, the use of terms such as straight or gay is also problematic. 'Gay' denotes a political position while homosexual identifies with being content with who they are and taking this position publicly. 'Straight' is used in contrast to 'bent', which is a pejorative term.
Kinsey (1948)[14] in his study reported that 4% were exclusively homosexual and 46% were somewhere between being exclusively homosexual or heterosexual. These findings have been taken for granted and are often used both by anti-gay and pro-gay lobbyists.
LeVay and Baldwin (2009)[16] note that sex is about identity as well as relationships. They also argue that the prevalence of bisexuality depends upon definitions being used (p 484). Sometimes questions are raised about the validity of this behavior. Malteson (1991)[17] points out that a bisexual male may have different emotional or physical attachments to males or females.
Bisexuality is an under-researched area in human sexuality. It is also seen as a somewhat grey area in our understanding of sexuality and encompasses sexual orientation, identity and behavior. Even though some studies have been conducted over the years following Kinsey's influential era, they have been unable to clarify many of the aspects of bisexuality and bisexual behavior. Research in bisexual sexual behavior received attention after the HIV epidemic became evident and role of bisexual men as a potential 'bridging group' between the genders was considered for possible interventions to reduce HIV transmission.
Defining and conceptualizing bisexuality is not straight-forward. There is a distinction between bisexual identity and behavior. Bisexual behavior may be more common than people identifying themselves as 'bisexual'. A wide range of sexual identities may accompany bisexual behavior. Sexual identities are also linked to gender identities, situational, cultural and environmental factors (men in prison etc). There is usually an asymmetry of practice, with sexual activities with one gender predominating with possible temporal variations. The variations in level of erotic desire and identity are less well- known and certain 'fluidity' is likely. An individual may see himself as heterosexual but their fantasy or behavior may be homosexual depending upon circumstances.
Development of sexuality is both multi-factorial and multi-faceted, with the interplay of various biological (e.g., genetic, hormonal, physical), physiological (e.g., genital arousal), psychological (e.g., psychodynamic, behavioral, cognitive-behavioral) developmental processes over the years. Sexual behavior is also dependent on psychological (e.g., attraction, desire, fantasy, eroticism, romantic), behavioral, physiological (arousal), emotional and social (e.g., social acceptance, self-identity, sexual politics) aspects. As our understanding of human behavior, psycho-social and biological development and brain functioning has improved, there is greater effort to integrate this knowledge to find an explanation of human sexual behavior. The sexual arousal pattern in bisexuals is not well-known. Understanding sexual arousal pattern in bisexuals is likely to provide better insight into intra- group range and diversity (if any) and how it differs from homosexual and heterosexual arousal patterns. This in turn could shed further light into the relationship between physiological functioning (e.g., arousal) and bisexual behavior and identity.
There has been a great deal of argument over whether sexuality is about sexual preference or sexual orientation. In the general dearth of studies in bisexuality, the studies of the brain structures, brain functioning, developmental aspects, behavioral, arousal pattern and mental health of homosexuals (mostly compared to heterosexuals) can provide valuable information in these areas as well as methodological designs.
Identity
The process of development and sexual identity formation may not follow a single pattern; sexual identity can be fluid and will depend upon what the external reference points are. A recent US study published in the Psychological Science on the debate of male bisexuality by Gerulf Rieger et al.[18] found that self-reported sexual arousal (to both male and female sexual stimuli) differed from genital arousal patterns, which were more strongly associated with one sex or the other (most of the time the pattern being similar to gay men). They concluded that 'male bisexuality is not simply the sum of, or the intermediate between, heterosexual and homosexual orientation. Indeed, with respect to sexual arousal and attraction, it remains to be shown that male bisexuality exists'. These findings were deemed controversial and drew mixed reactions from various groups. The study was criticized as being too simplistic/reductionist and not taking into account emotional and sensual aspects of sexuality.
There are no comparative data available from India, although there have been very few case studies done prior to the de-medicalization of homosexuality by the APA.[19] From a sex therapy clinic in north India, Verma et al.[20] reported less than 5% of attendees having had homosexual contact. A slightly lesser figure of 3% homosexual contact and 5% bisexual contact has been reported by Kalra and Kamath (2009)[21] in an unpublished study. Bhugra et al.(1997a)[22] and Bhugra (1997b)[23] studied coming out in South Asian gay men in the UK and western India, and found that persons most likely to come out were generally their friends. Family played a significant role in the lives of gay men, who found it very difficult to come out to their families. Interestingly, in another study Bhugra et al[24] found that sexual fantasy in gay men in Mumbai was largely same sex, compared with heterosexual men.
ISSUES IN MANAGEMENT
As noted above, the epidemiological data on prevalence of homosexuality and bisexuality in India are lacking, although a recent survey in India Today[25] revealed that in the northwestern Indian city of Jaipur, 15% of men had had sex with men. In Hyderabad, 61% approved of homosexuality. In Ahmedabad, in 2006, 56% reported having had a homosexual experience.
However, there is plenty of anecdotal evidence; even in metropolitan cities in India, psychiatrists use aversion therapies to change sexual orientation. It could be argued that this is simply a reflection of what Weeks (1981)[26] has already pointed out '…individuals are very much alike sexually and that it is an equally simple matter for all of them to confine their behavior to the single patterns which the (social) mores dictate'. Therapies used to change the orientation (or is it simply the behavior that is being changed?) arguably are ethically questionable.[27] The challenge for the therapists also is - where does bisexuality and bisexual behavior fit in all of this? Individuals may be pushed to seek treatment for their alternative sexualities because of family pressures to get married and produce heirs. Early studies reported treatment patterns in India mostly using behavioral approaches.[28,29] The distinction between ego dystonic alternative sexualities and ego syntonic ones need to be clarified and addressed.
The challenge for Indian psychiatry is not to isolate itself from global psychiatry but within the specific cultural context develop treatment guidelines which are clear and helpful. High levels of homosexual experiences do not translate necessarily into homosexuality or help-seeking. In the survey noted above, of those who admitted to having participated in an orgy, 52% of males had a male partner with them. This again confirms that there is a massive degree of variation in the community and the psychiatric profession needs to acknowledge this and take this into account. Overall, 12% of men and 6% of women had participated in orgies. Although the main emphasis was on understanding sexual desire and fantasies, it was largely based in cities. The important factor that all psychiatrists have to bear in mind is that their task is not only to be guided by the society, taking into account the cultural context, but it is essential that as opinion formers and leaders they educate the society and dispel myths. The fact that homosexual behavior has existed for centuries indicates that the 'normal variation' is part of human nature. A lack of space does not allow us to develop themes related to evolutionary psychiatry. It is sufficient to say that alternative sexualities exist and do influence social mores. It is important that young adults who may be struggling to deal with their sexual orientation and behavior are not branded psychiatrically ill and treated for it.
CONCLUSIONS
In recent times in the West, there has been a shift from seeing alternative sexualities as sinful or criminal activity. In some countries, criminal activity has given way to a grudging social acceptance. For example, in the UK, homosexual behavior was a crime till 1967 and then came a change in the age of consent and civil partnerships, which have produced a grudging acceptance. Various universities and academic institutions run courses on queer theory. The word of abuse 'queer' has been re-appropriated as a symbol of pride and points towards a sexuality which is more fluid. Sexual fluidity rejects the attempts of society to force everybody into pigeonholes and standardize sexual behavior. Similarly, in recent times various Presidents of the Indian Psychiatric Society have challenged the age old assumptions.[30,31]
Sathyanarayana Rao and Avasthi (2008)[32] have outlined a road map for sexual medicine from a psychiatric perspective; all these authors indicate a change in the views of psychiatrists to treatment of homosexuality. As agents of social change, Indian psychiatrists need to lead the charge in persuading society to accept sexual diversity and alternative patterns of sexual desire.
REFERENCES
1. Weiten W. Motivation and Emotion. In: Weiten W Psychology: Themes and Variations, 3rd edition. Pacific Grove, California, Brooks/Cole Publishing Company, 1995.p. 375-415. 2. Bullough V. Sexual Variation in Society and History. Chicago, University of Chicago Press, 1976. 3. Conner RP, Sparks DH, Sparks M. Cassell Encyclopaedia of Queer Myth, Symbol and Spirit. London, Bath Press, 1997.p. 342. 4. Vanita R, Kidwai S. Same Sex Love in India. 2nd edition. New Delhi, Macmillan India, 2000. p. 100-2. 5. Rowland DL, Inrcrocci L. Handbook of Sexual and Gender Identity Disorders. NJ, John Wiley and Sons, 2008. 6. Cohen L. The pleasures of castration. In: P Abramson, S Pinkerton (eds) Sexual Nature, Sexual Culture. Chicago, University of Chicago Press; 1995.p. 276-304. 7. Reddy G. With Respect to Sex: Negotiating Hijra Identity in South India. Chicago, University of Chicago Press, 2005. 8. Idnani A. A study of Hijras- Delhi. Dissertation submitted for M.A. Degree in Social Work. Tata Institute of Social Sciences, Mumbai, 1970. 9. Nerurkar N. A Study of Hijras- Hyderabad. Dissertation for M.A. in Social Work. Tata Institute of Social Sciences, Mumbai, 1971. 10. Goswami V. A study of Hijras- Agra. Dissertation submitted for M.A. in Social Work. Tata Institute of Social Sciences, Mumbai, 1973. 11. Gupta S. Portrayal of homosexuality in India arts. Presented at ANCIPS, Kolkata, 2008. 12. Sarvari AQ (ed) (1998): Kulliyat-i-Siraj. Delhi: Qaumi Council Barai farosh-i Urdu Zaban. 13. Foucault M. (1988, 1990): History of Sexuality (vols 1, 2 and 3). NY: Knopf Doubleday. 14. Kinsey. Sexual Behaviour in the Human Male. Philadelphia, WB Saunders, 1948. 15. Klein F. Sexual Orientation Grid Test. In: F Klein. The Bisexual Option, 2nd edition. Binghamton, NY, The Haworth Press, 1993. 16. LeVay S, Baldwin J. Human Sexuality. Sunderland MA, Sinauer Associates, 2009. 17. Malteson D. Bisexual feminist men. In: L Hutchins and L Kashmanu (eds) Bi Another Name: Bisexual People Speak Out. NY, Alyson, 1991. 18. Rieger G, Chivers ML, Bailey JM. Sexual arousal patterns of bisexual men. Psychol Sci 2005;16:579-84. 19. Pradhan PV, Ayyar KS, Bagadia VN. Male homosexuality: A Psychiatric Study of Thirteen Cases. Indian J Psychiatry 1982;24:182-6. 20. Verma KK, Khaitan BK, Singh OP. The frequency of sexual dysfunctions in patients attending a sex therapy clinic in north India. Arch Sex Behav 1998;27:309-14. 21. Kalra GS, Kamath R. Psychosocial profile of male patients presenting with sexual dysfunction. Unpublished MD dissertation 2009, Maharashtra University of Health Sciences, Nashik. 22. Bhugra D. Coming out by Asian gay men in the United Kingdom. Arch Sex Behav 1997;26:547-57. 23. Bhugra D. Experiences of being a gay man in urban India: A descriptive study. Sexual and Marital Therapy 1997;12:371-5. 24. Bhugra D, Rahman Q, Bhintade R. Sexual fantasy in gay men in India: A comparison with heterosexual men. Sexual and Relationship Therapy 2006;21:197-207. 25. Bamzai K. Mind Games. In: India Today 2009.p. 28-34. 26. Weeks J. Sexuality. London, Routledge, 1981. 27. Narrain A. Queer: Despised sexuality, law and social change. Bangalore, Books for Change, 2004. 28. Sakthivel LM, Rangaswami K, Jayaraman TN. Treatment of Homosexuality by Anticipatory Avoidance Conditioning Technique. Indian J Psychaitry 1979;21:146-8. 29. Pradhan PV, Ayyar KS, Bagadia VN. Homosexuality: Treatment by Behaviour Modification. Indian J Psychiatry 1982;24:80-3. 30. Reddy IR. Making Psychiatry a household word. Indian J Psychiatry 2007;49:10-8. 31. Mohandas E. Roadmap to Indian Psychaitry. Indian J Psychiatry 2009;51:173-9. 32. Sathyanarayana Rao TS, Avasthi A. Roadmap for sexual medicine: Agenda for Indian Psychiatric Society. Indian J Psychiatry 2008;50:153-4.
Gurvinder Kalra, Department of Psychiatry, T.N.M.C and B.Y.L.Nair Charitable Hospital, Mumbai Central, Mumbai - 400 008, India
Susham Gupta East London NHS Foundation Trust, Assertive Outreach Team - City and Hackney, 26 Shore Road, Hackney, London,E9 7TA
Dinesh Bhugra Professor of Mental Health and Cultural Diversity, Department of Health Service and Population Research, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK 43 HIV and mental health: An overview of research from India
Nishanth Jayarajan, Prabha S. Chandra
ABSTRACT
HIV/AIDS has gained prominence in India as a growing public health issue. There is a complex but significant interaction between mental health and HIV/AIDS. HIV affects mental health by its direct neurobiological action, the impact of having the illness, by its treatment including that for opportunistic infections and by its impact on the family. In addition, substance use and mental illness as vulnerability factors add to the complexity of assessment, differential diagnosis and management. This paper reviews literature published in India on the topic.
Key words: AIDS, HIV, India, mental health
INTRODUCTION
Since its emergence in the 1980s, HIV has been an enigma across medical specialties. Despite early calls for preventive administrative measures voiced by different parts of the medical community, including the psychiatric fraternity,[1] the disease has spread and India has several pockets of epidemics in different parts of the country.[2] Currently, India has an estimated prevalence of 0.23-0.33%.[3] Research from developing countries into this area has been exceedingly sparse, bearing in mind the fact that the epidemic has disproportionately affected the southern hemisphere. Public health efforts have been lethargic in tackling the double danger of HIV and mental illness.
Assessment and management of mental disorders is integral to an effective HIV/AIDS intervention program. Mental health professionals will increasingly be called upon to assist in the management of people living with HIV/AIDS. Thus psychiatrists will need to be familiar with disorders that are prevalent in HIV infection and also the interface of treatment, including HAART with mental health. This article is an attempt to throw light on these issues from an Indian perspective, by putting together the available data from Indian studies in this regard.
BIDIRECTIONAL LINK OF HIV AND MENTAL ILLNESS
The relation between HIV and mental illness has been studied by examining HIV infection in those with mental illness and mental illness in those with HIV. However, there are many common factors in both, such as homelessness, incarceration, poverty and substance misuse. There is some evidence to suggest that HIV risk in people with severe mental illness is mediated through substance misuse.[4] In addition to this avenue of investigation, there has been exploration of the impact of psychological morbidity on disease progression, response to treatment and outcome of treatment.
HOW ARE THE MENTALLY ILL AT MORE RISK?
There is increasing evidence of prevalence of HIV and high-risk behavior among psychiatric patients. There is a significant body of research from India [Table 1] examining the link between HIV and mental health. Evidence from developing countries is more limited[5] with four studies from South Asia.[6- 9] HIV prevalence of 1.7% has been reported among psychiatric inpatients.[9] The predominant risk behavior among psychiatric patients in India is unprotected heterosexual intercourse, which reflects the common mode of transmission in the country.[6,10-12] Prevalence of risk behavior ranges from a lifetime history in 26% (men) and 11% (women) and recent history in 5% men and 6% women[10-12] although previously much higher rate of 51% has been reported in inpatients.[7] Patients with comorbid substance misuse are more likely to engage in HIV risk behavior and lack of adequate knowledge about HIV also contributes to it.[7] Women with severe mental illness have a higher prevalence of high-risk behavior in those with a history of abuse.[10-12]
WHAT ARE THE PSYCHIATRIC COMORBIDITIES IN HIV?
Psychiatric comorbidity in HIV ranges from minor cognitive deficits to frank psychosis. Since the early 1990s there have been efforts to document the neuropsychiatric aspects of HIV.[13] Psychiatric manifestations are more in HIV-affected individuals as compared to other STDs.[14] There is considerable evidence that depression and anxiety are prevalent diagnoses among those with HIV infection.[15-16] Cognitive deficits in HIV vary from subtle abnormalities in attention and concentration through to gross psychomotor retardation and dementia. It is well established that HIV associated dementia involves most cognitive domains, but evidence on early changes are less consistent[17] [Table 1].
Cognitive deficits
In India, significant cognitive deficits are reported in advanced HIV disease in patients not receiving HAART. In one study, 56% of PLWHA were demonstrated to have impairment in at least two cognitive domains.[18] Neurocognitive disturbances in asymptomatic HIV infection have been a subject of research interest in view of the implications on its influence on occupational functioning. Between 60-90% of asymptomatic subjects with HIV have been reported to have cognitive deficits.[19,20] Specific deficits have been reported in digit symbol substitution test, trail making test and controlled word association test.[21] The duration of detected illness does not appear to have a significant relation to the degree of deficits. There have been reports of neurocognitive impairment increasing with worsening clinical status.[22] A follow-up study of neuropsychological function at baseline with six-monthly reassessments found that only one of 10 cognitive variables-visual working memory showed deterioration over 30 months.[23]
There has been extensive research into differences in neuropathology between different clades of HIV using animal studies and human fetal cells. HIV 1 clade C, the prevalent type in India has been found to have less toxic form of viral protein as compared to the clade B. [24,25] Mishra et al.[25] suggest this as a possible reason for the difference in degree of HIV-1 associated neurological deficits in India. Delirium is common in HIV and those with advanced AIDS and dementia are particularly vulnerable. Diarrhea, hypoxia related to pneumocystis carini infection, neuro infections, alcohol withdrawal and some drugs used in treatment could all contribute. In the Indian context, one should also enquire for use of alternate forms of treatment or traditional medicines that may contribute to delirium.
Psychosis
Psychotic symptoms seen in HIV-infected individuals may be primary or secondary.[26] Occasionally psychotic symptoms may be the presenting complaints of an HIV illness.[27] One case report highlights the presentation of progressive multifocal leukoencephalopathy (PML) being camouflaged by catatonic symptoms, thereby emphasizing the need for detailed investigations in such a presentation.[28] Primary psychosis does not yield any signs of HIV cerebral disease whereas secondary psychosis often occurs in the context of global (encephalopathy) or localized pathology (most often lesions of the left temporal lobe and diencephalon). Other factors that need to be considered in the differential diagnosis include presence of opportunistic infections like tuberculoma, toxoplasmosis and cryptococcal meningitis, which may present as acute psychosis in the initial stages.
Drugs like INH can also contribute to psychosis and co occurrence of neurosyphilis may also lead to psychosis. Several patients with comorbid substance use may present with withdrawal related psychosis following a sudden infection or hospitalization.
Depression
Emotional problems are among the most common symptoms in HIV patients with up to 98.6% prevalence.[29] Depression is a prevalent comorbidity in HIV infection as well as a recognized side-effect of NRTI, Protease inhibitors and NNRTIs. It may also be the first presenting symptom in an HIV case.[30] It is essential to discriminate between normal response to a life threatening illness, clinical manifestation of HIV and depressive episode while recognizing that all three can coexist. As in other serious medical illness, anhedonia may be the most reliable indicator of severe depression. HIV infected individuals are recognized to be at high risk of suicide in the period immediately after coming to know of seropositive status, especially if they have a past psychiatric history.[4] Chronic pain, commonly encountered in HIV, both due to disease as well as treatment related side-effects, is often associated with depression.
Mania
Mania is overrepresented in HIV infection compared to general population. A case series explored the various possible associations of HIV and mania like manic symptoms being a direct effect of the illness, effect of HAART drugs, or as a reaction to disclosure of the diagnosis.[31] Although manic episodes can occur early in the infection, it is more common in later phases of the infection, often associated with cognitive deficits and can be a presentation of HIV dementia or associated with psychosis.
Anxiety disorders
Among those with HIV, up to 28% may have adjustment disorder,[32] 25-36% may suffer from anxiety[4,11] and there is a higher prevalence of PTSD scores among people living with HIV/AIDS.[33] Anxiety is also prevalent among children with HIV (18%).[34]
A planned wedding or sex between the couple, in the context of being diagnosed with HIV, can precipitate and maintain anxiety disorders. Drugs, both prescribed and illicit should be considered in the etiology but most commonly in this population, alcohol misuse can maintain the disorder resulting in poor response to treatment. Psychiatric assessment should aim at identifying specific precipitating factors for anxiety disorder.
Suicide
HIV can be a significant risk factor for suicide. Chronic pain, anxiety and depression should prompt a thorough suicidal risk assessment. Suicidal attempt is most likely to occur in those with a history of psychiatric illness and in the immediate aftermath of diagnosis with HIV.[4]
Bereavement
Complicated grief reactions among relatives are common sequelae of death due to HIV infection. Up to 40% of HIV infected children have been reported to be orphaned.[35] HIV deaths may often be stigmatized leading to a lack of funeral rituals, which are an important part of societal mourning in this region.[36] Psychological intervention is appropriate if grief is unresolved in the context of dissipating and often hostile social support system.[37]
HOW DO PSYCHOLOGICAL FACTORS AFFECT PROGNOSIS IN HIV?
Psychoneuroimmunology
Chittiprol et al.[20] followed up a sample of 120 HIV seropositive (including HIC 1 C), neurologically asymptomatic subjects to investigate endocrine functions. They attribute the finding of consistently high cortisol response but inconsistent ACTH response to challenge in seropositive to HIV-1C infection adversely affecting the adaptability of the HPA axis to the stressor/s. They also found that the poor response of autonomic system in HIV positive subjects (as measured by epinephrine and norepinephrine levels following cognitive challenge) was consistent over time. A correlation between QOL scores on the physical health domain of QOL and CD4 counts was reported by Kohli et al.[38] Chandra et al.[7] found low CD4 counts (,200/mm) to be associated with low scores on the psychological and social relationships domain.
Adherence to treatment
Psychiatric illness can be an important factor determining the adherence to treatment of HIV infection. Those with mental illness can have difficulty in adhering to the medication routine. Negative attitudes from health professionals may lead the patient to disengage from treatment.[39] In a sample of 310 patients on HAART, Sarna et al.[40] found that patients with severe depression were four times more likely to report lower adherence to treatment.
Childhood psychiatric disorder in HIV
Children with HIV infection often grow up in stressful environment. Most acquire the disease through maternal transmission and are faced with parents living with a chronic life threatening condition. Parents' death in such circumstances can leave the child stigmatized and with fragmented social support. Grover et al.[41] studied behavioral disorder by comparing 140 HIV positive children with age and family income matched HIV negative controls using Child Behavior Checklist. 19.3% of HIV infected children scored within the normal range on CBC in contrast to 81.7% of controls. The authors found that HIV infection and disturbed family environment were the most consistent correlates of behavioral disorder. There has been one unpublished data cited by Rao et al.[34] In 22 HIV infected pediatric outpatients, a prevalence of 45% psychiatric disorders (using K-SADS-PL) and 40% prevalence of behavioral problems (Child Behavior Checklist) are reported.
WHAT ARE THE PSYCHOSOCIAL ASPECTS OF LIVING WITH HIV/AIDS?
The earliest psychological impact of being diagnosed with HIV can be understood within the framework of Kübler-Ross cycle of grief involving denial, anger, bargaining, depression and acceptance. However, the most important additional aspect in HIV/AIDS is the social stigma. Soon after becoming aware of one's seropositive status, the HIV infected patient often has to work through life changes including relationships, family, employment, finances etc. Disclosure of seropositivity can be a stressful decision. If the individual feels the need to disclose and the outcome of disclosure is positive, this can be associated with better quality of life.[11] Quality of life in the early asymptomatic stage of illness is usually better than early symptomatic or AIDS stage with impact on both physical and psychological domains. Quality of life can be influenced by educational status and income as well.[42] When symptomatic a range of factors such as physical health, employment and social and biological function can impact upon quality of life.[38] Tarakeshwar et al.[43] studied 50 adults with HIV with regards to their beliefs that helped manage the illness and found that all 50 believed God to be a benevolent force. The spiritual practices were described as enabling them to face their troubles with less fear and greater confidence. In most low and middle- income countries only a minority of the population have access to HAART, and a significant proportion of patients end up without active treatment.
The key issues at the interface of psychiatry and palliative care for HIV are predominantly related to disorders such as delirium, dementia, substance dependence or withdrawal and depression. Psychiatrists may also be called upon to assess competence of the patient to make end of life decisions, offer advice on difficult family dynamics as well as staff stress and burnout.
Women with HIV
Joseph and Bhatti[44] studied psychosocial problems in 30 HIV positive women and among other difficulties found compromised help seeking as a consequence of stigma with gender discriminatory and inadequate care. Gupta et al.,[45] found that HIV-positive women were significantly more likely to report marital dissatisfaction, a history of forced sex, domestic violence, depressive symptoms and husband's extra marital sex when compared to HIV- negative women. Kohli et al.[38] also reported on significantly lower QOL scores in women despite having less advanced disease. Another study comparing quality of life in men and women with HIV found that men reported better quality of life in the environmental domain and women had higher scores on the spirituality/religion and personal beliefs domain.[46]
Injectable drug users
The prevalence of HIV among IDUs has increased over time. [47] There is evidence for participation by women IDU in HIV prevention programs, though the effect was seen more in terms of practicing safer sex than safer injections.[48]
Mental health Issues among MSM with HIV Infection
Men who have sex with men are at high risk for HIV and this group has been poorly studied in India compared to the Western world. This group includes Kothis (receptive, feminine), Panthis (penetrative, masculinized) and Hijras (transgender, hermaphrodite, castrated). The Kothis and Hijras are more likely to bear the brunt of social stigma with HIV as they are bracketed with female commercial sex workers and have less support coming their way.[49] Pandya[50] has described the range of psychosocial stressors that are faced across the lifespan by MSM in India. It is crucial that psychiatrists sensitively inquire regarding sexual preferences even when the patient is in a heterosexual relationship.
CONCLUSIONS
From the available data, the intertwined relationship of HIV and psychiatric disorders is clear. Mental health professionals need to be aware of the varied psychiatric manifestations of HIV, and the impact of HIV on a pre-existing psychiatric condition. In addition, other issues like impact of opportunistic infections on the brain, the impact of illness on the life of the individual, the association of substance use and HIV, and the relationship of treatment and mental health need to be addressed. HIV challenges the psychiatrist to consider systematic and diverse methods in assessment, consider several possibilities in the differential diagnosis and also be aware of the problems related to use of different medications. In developing countries like India, specific issues such as comorbid infections, IV drug use and stigma and inadequate facilities for HAART and palliative care add to the mental health burden.
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Kohli RM, Sane S, Kumar K, Paranjape RS, Mehendale SM. Assessment of quality of life among HIV-infected persons in Pune, India. Qual Life Res 2005;14:1641-7. 39. Krishna V, Bhatti R, Chandra P, Juvva S. Unheard voices: Experiences of Families living with HIV/AIDS in India. Contemp Fam Ther 2005;27:483-506. 40. Sarna A, Pujari S, Sengar AK, Garg R, Gupta I, Dam J. Adherence to antiretroviral therapy and its determinants amongst HIV patients in India. Indian J Med Res 2008;127:28-36. 41. Grover G, Pensi T, Banerjee T. Behavioural disorders in 6-11-year-old, HIV-infected Indian children. Ann Trop Paediatr 2007;27:215-24. 42. Wig N, Lekshmi R, Pal H, Ahuja V, Mittal CM, Agarwal SK. The impact of HIV/AIDS on the quality of life: A cross sectional study in north India. Indian J Med Sci 2006;60:3-12. 43. Tarakeshwar N, Srikrishnan AK, Johnson S, Vasu C, Solomon S, Merson M. A social cognitive model of health for HIV-positive adults receiving care in India. AIDS Behav 2007;11:491-504. 44. Joseph EB, Bhatti RS. Psychosocial problems and coping patterns of HIV seropositive wives of men with HIV/AIDS. Soc Work Health Care 2004;39:29-47. 45. Gupta RN, Wyatt GE, Swaminathan S, Rewari BB, Locke TF, Ranganath V, et al. Correlates of relationship, psychological, and sexual behavioral factors for HIV risk among Indian women. Cultur Divers Ethnic Minor Psychol 2008;14:256-65. 46. Chandra PS, Satyanarayana VA, Satishchandra P, Satish KS, Kumar M. Do Men and women with HIV differ in their quality of life? A study from South India. AIDS Behav 2009;13:110-7. 47. Sarkar S, Das N, Panda S, Naik TN, Sarkar K, Singh BC, et al. Rapid spread of HIV among injecting drug users in north eastern states of India. Bull Narc 1993;45:91-105. 48. Kumar MS, Sharma M. Women and substance use in India and Bangladesh. Subst Use Misuse 2008;43:1062-77. 49. Dowsett G. HIV/AIDS and homophobia: Subtle hatreds, severe consequences and the question of origins. Culture Health Sexuality 2003;5:121-36. 50. Pandya A. Voices of Invisibles: Coping responses of Men who Have Sex with Men (MSM). Strength Based Strategies International Conference Towards Strength Based Strategies that Work with Individuals, Groups and Communities. 2006. p. 10-2. November. H y d e r a b a d , I n d i a . A v a i l a b l e f r o m : http://www.strengthbasedstrategies.com/PAPERS/12%20PandyaFormatted.pdf. [accessed on 2009 Jan 17]. 51. Mandal MC, Mullick SI, Nahar JS, Khanum M, Lahiry S, Islam MA. Prevalence of psychiatric ailments among patients with sexually transmitted disease. Mymensingh Med J 2007;16:S23-7. Nishanth Jayarajan Junior Resident, Department of Psychiatry,
Prabha S. Chandra Professor of Psychiatry, Department of Psychiatry, NIMHANS, Bangalore, India 44 Publications on community Psychiatry
R. Thara, Sushma Rameshkumar, C. Greeshma Mohan
ABSTRACT
Care and treatment outside the setting of mental hospitals have been termed community psychiatry. This paper, based largely on publications on this subject in the IJP, discusses work on development of mental health services outside the hospitals, National and District Mental Health Programs, some accounts of Indian families, alternative modes of treatment in communities and a few miscellaneous issues. Very few papers are data driven and most of them are descriptive and opinionated.
Key words: Community psychiatry, programs, publications
IJP-PUBLICATIONS- COMMUNITY MENTAL HEALTH
Before I proceed to define and discuss research in Community Psychiatry in India, I wish to state that this review, based only on publications in the IJP, is by no means comprehensive. It does not include the large body of Indian work which has been published in other journals such as the British Journal of Psychiatry, World Psychiatry, International J of Social Psychiatry, Int. Review of Psychiatry and many others. This also does not include abstracts of papers presented at the various conferences of the Indian Psychiatric Society, since they are not truly peer reviewed publications. Since not much of actual research has been done on this subject and most of the papers are descriptive accounts or view points, I prefer to refer to it as publication rather than research.
INTRODUCTION
The word community means different things to different people, but is generally used to denote a particular geographical and administrative area, a relatively wel-integrated neighbourhood and locality. It also alludes to areas outside big hospitals. Community Psychiatry (CP) has been defined in many ways. While it originates from certain historical background of "deinstitutionalization" in western countries, it generally has denoted the development of services in many of the developing countries. Many developing countries including India did not have an adequate number of institutions to care for the mentally ill. Most care in fact took place in the community and family. This was with or without the involvement of mental health services depending on their availability.
This is why the term community psychiatry in India alludes to establishment of new services/programmes in the community rather than the process of de- institutionalization.
Szmukler and Thornicroft[1] define community psychiatry as follows:
"Community psychiatry comprises the principles and practices needed to provide mental health services for a local population by (i) establishing population-based needs for treatment and care; (ii) providing a service system linking a wide range of resources of adequate capacity, operating in accessible locations and (iii) delivering evidence based treatments to people with mental disorders
These 'principles' of community psychiatry, proposed by Caplan and Caplan,[2] have also proved useful and valid to varying degree in defining the subject. These principles include:
1. Responsibility to a population, usually a catchment area defined geographically 2. Treatment close to the patient's home 3. Multi-disciplinary team approach 4. Continuity of care 5. Consumer participation 6. Comprehensive services
INDIA
Over the last three to four decades, community psychiatry in India has made substantial advances. When mental hospitals were found to be inadequate, a number of initiatives including the National Mental Health Programme were started as community based activities. Now, it appears that about 20% of the country has had the benefit of integration of mental health with general medical services in about 100 districts all over the country. There are also initiatives by non-governmental organizations and private institutions.
Given this background and keeping in mind the inevitable overlap with other chapters in this volume, the issue covered will be the following (not necessarily in that order):
1. Development of mental health services 2. National Mental Health Programme (NMHP) and the District Mental Health Programme (DMHP) 3. Primary care psychiatry 4. Families 5. Other miscellaneous topics
Community MH Programmes
The late Dr. R.L. Kapur[3] who has written extensively on community mental health, began the story of community psychiatry with Dr. Vidya Sagar who, as early as in the 1950s, involved family members of patients admitted into Amritsar Mental Hospital. This experiment not only reaped rich benefits but also initiated a major movement of involving families in the care process. Now family wards are located in several institutions like NIMHANS, CMC, Vellore and the IMH, Chennai.
There have been some long standing, well known community-based projects in India. One of them is the Raipur Rani experiment. Wig et al. in 1981[4] described in great detail the entire study of over 60,000 persons in Haryana, the methodology, the tools used and the means in which the community was involved in all activities. The same authors have also written on the organization of mental health services through primary/peripheral care centres based on the Raipur Rani experience.
The other well known community study has been at Sakalwara in Karnataka. Chandrasekar et al.[5] describe the three-year experience in a paper published in 1981 and the lessons that can be learnt from this. From the same centre, Mohan Isaac et al. describe the development and evaluation of a training programme to effect mental health care delivery through a PHC in rural Karnataka.[6]
The other large studies have been the one at Barwani by Chatterjee et al.[7] and at Thiruporur by SCARF.[8] Publications on these can be found in other journals.
MENTAL HOSPITALS
In their interesting article on Agra mental hospital, Sudhir Kumar and Rakesh Kumar (2008) describes the growth of what was called lunatic asylums in India during the British rule. The institution went through many phases including what they term the golden period when K.C. Dube was at the helm of affairs- characterized by a lot of international research including the well known WHO study the IPSS. Now, community care is well developed in Agra and the institute itself has a department of research and rehabilitation.[9]
O. Somasundaram has in an interesting publication named "Asylums and authors" described the several historical figures associated with mental asylums.[10]
NATIONAL MENTAL HEALTH PROGRAMMES
There have been a lot of descriptive papers on NMHP and DMHP. Unfortunately, very few have been data-based and few published in the IJP; a mid-term appraisal by Murthy makes interesting reading.[11]
Three other publications from NIMHANS deal with other issues like management of priority mental disorders in a community, evaluation of a pilot training programme and a follow-up of rural mentally ill.[12-14]
MENTAL HEALTH SERVICES
Desai[15] traced the development of mental health services in India and made some comparisons. He argued that a "truly comprehensive and meaningful conceptualization of community mental health can also include many of these aspects, and that public mental health is no more than community mental health". He also opined that attention should be paid to social issues such as poverty, homelessness, violence, urbanization homeless populations, refugees, disaster affected populations, as also the health issues of the affluent classes ".
The next phase of community-based services started with the beginning of psychiatric units in general hospitals (GHPUs)., Wig in his 1978 publication mentioned that the first such unit was set up in 1933 at the R.G.Kar Medical College at Kolkata followed by many others in the 60s. There seem to be close to 300 GHPUs now.[16] PRIMARY CARE PSYCHIATRY
It has been suggested that in many developing countries, primary care psychiatry can effectively replace the term community psychiatry. In developing countries, where the number of specialist mental health professionals is very small in comparison to the actual demand, the provision of mental health services would remain a dream unless psychiatry was firmly rooted in primary health care.
Training programmes form a critical part of primary care psychiatry involving as it does training of several types of professionals such as PHC doctors and nurses, and Community level Workers. In 1989, Shamsundar et al.[17] described the training programme of GPs based on a ICMR study. This was a multi site study initiated by ICMR "Training Programme in Psychiatry for non psychiatrist primary care doctors" and was held in 1982-83. Manuals were developed and an evaluation of the training programme done.
Murthy and colleagues[18] describe the use of case vignettes for the assessment of GPs during their training. In 1985, Gautam[19] discussed the development and evaluation of training programmes for primary care in India. The other publications on training have been by Devi (short term training), and Nagarajiah et al. on evaluation of such training.[20,21]
Inspired by eye camps, psychiatric camps were organized in places where the distance to the nearest psychiatric facility was long. The village leaders were also involved in the therapeutic process and in stigma reduction efforts.[22]
Community mental health also includes school mental health. This was pioneered at NIMHANS by Malavika Kapur. School Mental Health is an important element of community psychiatry. The programme at NIMHANS developed manuals, trained school teachers to diagnose children with emotional problems and to counsel them. It was evaluated with satisfactory results.[23]
ALTERNATIVE MEDICAL PRACTICES AND NON MEDICAL HEALING
It is widely known that even today religious healing takes place in select temples and durghas. The mode of healing varies from place to place. The entire country was put to shame by the Erwadi tragedy which saw 26 patients chained in a hut close to a religious healing site in Tamil Nadu who were burnt to death by an accidental fire which broke out one night.
The Erwadi tragedy and its implications have been well written by Trivedi in an editorial[24] and James Anthony[25] in a long letter to the editor in 2002. Both while lamenting the inhuman tragedy have urged the mental health community and policy makers to have a relook at the framework of mental health services in general and community psychiatry in particular.
Somasundaram has given a very lucid account of religious treatment of the mentally ill in several Hindu temples and durghas in Tamilnadu.[26] Joel et al. conducted in CMC, Vellore a bio medical educational intervention to change explanatory models of psychosis among CLWs in south India.[26]
FAMILIES
Families in general and those of the mentally ill have been a subject of some research. There have been some general accounts of families in India. Ramanujam[27] dealt with the psychology and sociology of families. As early as 1967, Rose Chacko underscored the importance of the Indian family in the process of psychosocial rehabilitation.[28]
In 1967, Sethi BB conducted a community survey on 300 urban families in Lucknow studying social and demographic features of families.[29] The same author also discussed in his 1978 publication the need to understand the social processes in India to care better for the mentally ill.[30] In 1981, he wrote an editorial on the subject of family planning and its implications for mental health.[31]
MISCELLANEOUS
Medical practices among an Indian tribe have been described by Vinod Kumar Singh in 1972.[32] An interesting epidemiological study of a Himalayan tribe by Ghosh et al. found psychiatric morbidity in 50% of the tribe with more women being affected.[33] B oral et al. studied different treatment methods used by the mentally ill and their social acceptance.[34]
Srinivasan and Suresh[35] conducted a study on the prevalence of non psychotic mental morbidity in a primary care setting and have identified variables such as female sex, unskilled labour, younger age etc to be more associated with this. In 2004, Roy Abraham elucidated the mental health issues in the south Asian region.[36] In the same year, Srinivasa Murthy detailed the challenges and resources in the utilization of human resources in mental health care.[37]
In the editorial on the impact of rapid urbanization on mental health, Trivedi et al.[38] opined that South-Asian countries by virtue of their developing economies and poverty level are particularly vulnerable and tend to have a higher burden of diseases with an already compromised primary health care delivery system. The range of disorders and deviancies associated with urbanization is enormous and includes psychoses, depression, sociopathy, substance abuse, alcoholism, crime, delinquency, vandalism, family disintegration, and alienation.
Seasonal variation was reported by Singh et al.[39] Their study showed a significant relationship between utilization of psychiatric patients, especially with mood disorders and neurotic, stress related and somatoform disorders with season (summer and autumn respectively).
Some innovations in mental health have also been described. [40] One of them is the establishment of ambulatory services for the mentally ill.
For the first time, Karnataka State Mental Health Authority (KSMHA), in coordination with Government of Karnataka, Rotary Club, Bangalore West, and ACMI, a non-governmental organization (NGO) began such a service in the city of Bangalore. The request for such services had come from NGOs formed by families of the mentally ill. Guidelines were framed and approved by the KSMHA. Funding for this project has come from NGOs and the KSMHA. This has been functioning from October 2008 onwards. It appears that this is a model of community care which can be replicated in other parts of India as well.
NON-GOVERNMENTAL ORGANIZATIONS
In the last two decades, NGOs working on mental health have played a major role in filling many gaps in community mental health. These have ranged from rehabilitation and after care of severely disabled persons with psychoses, to children, substance abuse, elderly and suicide. A book by Patel and Thara[41] provides a comprehensive account of the role of NGOs in India.
CONCLUSION
It can be said that community psychiatry has been evolving slowly, but surely, over the last few decades. It has largely been marked by anecdotal reports, program descriptions and individual descriptions. The NMHP and DMHP have been erratic in their functioning and have not generated much evaluable data. There is no central, unified policy on community mental health in India. Unless this happens, it is likely that publications on community psychiatry will continue to be descriptive and anecdotal. REFERENCES
1. Szmukler and Thornicroft. Textbook of Community Psychiatry. Oxford. New York: 2001. 2. Caplan G, Caplan RB. Development of community psychiatry concepts. In: Comprehensive Textbook of Psychiatry. Freedman AM, Kaplan HI, editors. Baltimore, MD: Williams and Wilkins; 1967. 3. Kapur RL. Priority in mental health workshop on priorities in developing countries. Ind J Psychiatry 1971;13:175-82. 4. Wig NN, Murthy SR, Harding TW. A model for rural psychiatric services- Raipur Rani Experience. Ind J Psychiatry 1981;23:275-90. 5. Chandrashekar CR, Issac MK, Kapur RL, Parthasarathy R. Management of priority mental disorders in the community. Ind J Psychiatry 1981;23:174-8. 6. Issac MK, Kapur RL, Chandrasekar CR, Kapur M, Parthasarathy R. Mental health delivery in rural primary health care - development and evaluation of a pilot training programme. Ind J Psychiatry 1982;24:131-8. 7. Chatterjee S, Patel V, Chatterjee A, Weiss HA. Evaluation of a community based rehabilitation model for chronic schizophrenia in India. Br J Psychiatry 2003;182:57-62. 8. Thara R, Islam A, Padmavati R. Beliefs About Mental Illness: A Study of a Rural South Indian Community. Int J Mental Health 1998;27:70-85. 9. Kumar S, Kumar R. Institute of mental health and hospital, Agra: Evolution in 150 years. Ind J Psychiatry 2008;50:308-12. 10. Somasundaram O. Asylums and Authors. Ind J Psychiary 2004;46:29-32. 11. Murthy SR. National Mental Health Programme In India (1982-1989). Mid- Point Appraisal 31:267-70. 12. Chandrashekar CR, Issac MK, Kapur RL, Parthasarathy R. Management of priority mental disorders in the community. Ind J Psychiatry 1981;23:174-8. 13. Issac MK, Kapur RL, Chandrasekar CR, Kapur M, Parthasarathy R. Mental health delivery in rural primary health care - development and evaluation of a pilot training programme. Ind J Psychiatry 1982;24:131-8. 14. Parthasarathy R, Chandrasekar CR, Issac MK, Prema TP. A profile of the follow-up of the rural mentally ill. Ind J Psychiatry 1981;23:139-41. 15. Desai NG. Public mental health: An evolving imperative. Ind J Psychiatry 2006;48:135-7. 16. Wig NN. Psychiatric units in general hospitals-the right time for evaluation. Ind J Psychiatry 1978;20:1-5. 17. Shamasundar C, Jacob J, Reddy PR, Chandramauli AV, Isaac MK, Kaliaperumal VG. Training General Practioners In Psychiatry. An ICMR Multi-Centre Study 1989;31:271-9. 18. Murthy SR, Shamasundar C, Jacob J, Reddy PR, Chandramauli AV, Isaac MK, et al. Clinical Vignettes For Assessment Of Training. Gen Practition In Psychiatry 1989;31:280-4. 19. Gautam S. Development and evaluation of training programmes for primary mental health care. Ind J Psychiatry 1985;27:51-62. 20. Devi S. Short-term training of medical officers in mental health. Ind J Psychiatry 1993;35:107-10. 21. Nagarajiah, Reddamma K, Chandrasekar CR, Issac MK, Murthy SR. Evaluation of short- term training in mental health for multipurpose workers. Ind J Psychiatry 1994;36:12-7. 22. Kapur RL, Chandrashekar CR, Shamasundar C, Isaac MK, Parthasarathy R, Shetty S. Extension Of Mental Health Service Through Psychiatric Camps: A New Approach 1982;24:237-41. 23. Kapur M, Cariappa I. Evaluation of training programme for school teachers in student counselling. Ind J Psychiatry 1978;20:289-91. 24. Trivedi JK. Lessons from the Erwadi Tragedy For Mental Health Care In India. Ind J Psychiatry 2001;43:362-77. 25. Anthony J. Let us learn the right lessons from Erwadi Letter to the Editor. Ind J of Psychiatry 2002;44:186-92. 26. Joel D, Sathyaseelan M, Jayakaran R, Vijayakumar C, Muthurathnam S, Jacob KS. A biomedical educational intervention to change explanatory models of psychosis among community health workers in South India. Ind J Psychiatry 2006;48:138-42. 27. Ramanujam BK. Some Thoughts on Psychological Problems of Families in India. Ind J Psychiatry 1967;9:9-14. 28. Chacko R. Family Participation in the Treatment and Rehabilitation of the Mentally Ill. Ind J Psychiatry 1967;9:328-33. 29. Sethi BB, Gupta SC, Kumar R. 300 Urban Families. Ind J Psychiatry 1967;9:280-302. 30. Sethi BB, Manchanda R. Family Structure And Psychiatric Disorders. Ind J Psychiatry 1978;20:283-8. 31. Sethi BB. Family Planning and Mental Health. Ind J Psychiatry 1981;23:101-3. 32. Singh VK. Tribes medical practices among an Indian tribe Singh VK. Ind J Psychiatry 1973;15:300-2. 33. Ghosh, et al. Psychiatric morbidity in a sub Himalayan tribal community an epidemiological study. Ind J Psychiatry 2004;46:326-32. 34. Boral GC, Bagghi R, Nandi DN. Acceptance, oral GCAN opinion survey about the causes and treatment of mental illness and the social acceptance of the mentally ill patients. Ind J Psychiatry 1980;22:235-8. 35. Srinivasan, Suresh. Character of non-psychiatric morbidity in a primary care population. Ind J Psychiatry 1990;32:145-51. 36. Roy A, Kallivayalil. Mental Health Issues In South Asia Region. Ind J Psychiatry 2004;46:295-8. 37. Srinivasa R Murthy. Human resources for mental health care in india challenges and opportunities. Ind J Psychiatry 2004;46:361-6. 38. Trivedi JK, Sareen H, Dhyani M. Rapid urbanization - Its impact on mental health: A South Asian perspective Indian J Psychiatry 2008;50:161-5. 39. Singh GP, Chavan BS, Arun P, Sidana A. Seasonal pattern of psychiatry service utilization in a tertiary care hospital. Ind J Psychiatry 2007;49:91-5. 40. Chandrashekar H, Prashanth NR, Naveenkumar C, Kasthuri P. Innovations in Psychiatry: Ambulatory services for the mentally ill. Indian J Psychiatry 2009;51:169-70. 41. Patel V, Thara R, editors. Meeting mental health needs in developing countries: NGO innovations in India, Sage (India), New Delhi: 2003.
R. Thara Sushma Rameshkumar C. Greeshma Mohan Schizophrenia Research Foundation (SCARF), Chennai, India 45 Psychiatric rehabilitation: A review
H. Chandrashekar, N. R. Prashanth, P. Kasthuri, R. Madhusudhan
ABSTRACT
Psychiatric rehabilitation is an important component in the management of the mentally ill. This article presents a selective review of the publications in this journal. Questions addressed in this review range from assessment of rehabilitation needs to different rehabilitative approaches. Although the number of publications providing the answers is meager, there are innovative initiatives. There is a need for mental health professionals to publish the models they follow across the country.
Key words: Rehabilitation
INTRODUCTION
Psychosocial rehabilitation is a therapeutic approach that encourages a mentally ill person to develop his or her fullest capacities through learning and environmental support.[1]
Psychiatric rehabilitation and psychiatric treatment are separate, yet equally important complementary components of mental healthcare. Even as psychiatric treatment (Pharmacological and psychological) aims at controlling psychiatric symptoms, psychiatric rehabilitation focuses on functioning and role outcomes. The new focus of rehabilitation is on wellness and optimum quality of life.
The rehabilitation program should start right from the first time the patient has come into contact with a mental health professional. A clinician waiting to start rehabilitation after the patient becomes asymptomatic, may not benefit the patient or the family in the long run.[2]
This article reviews publications in the IJP from its inception to date, in the area of rehabilitation. We have tried to summarize these articles and suggest future directions.
This includes editorials, commentaries, review articles, book reviews, and case reports.
Literature review
The first available publication regarding rehabilitation in our research is by Gupta et al.,[3] from the Hospital for Mental Diseases, Ranchi. They studied the possible causes and nature of chronicity among psychiatry patients and tired to categorize patients on the basis of residual assets (Functional ability). They found that 269 patients out of 450 (total bed strength) had stayed in the hospital for a period of longer than two years at a stretch. Thus 60% of the mental hospital beds were occupied by chronic patients. They evaluated their need of staying, and found that 6.5% of these chronic patients required full hospitalization, 71.75% required limited hospitalization and were capable of productive work under supervision, and 22% were there purely for social reasons and hospitalization was not necessary. They suggested rehabilitation services, including an occupational therapist, to be attached to every mental hospital, which could cater to the need of a majority of such chronic patients who languished.
Schmidt[4] in his article, 'A measurement of rehabilitation of psychiatric patients,' comments that in psychiatry, as in general medicine, a full restitutio ad integrum cannot be expected even after the most efficient treatment, although, functioning can fortunately be restored after the disease. He has reported from a community-based mental health review in Sarawak, a state in the federation of Malaysia. They focused on patients in terms of rehabilitation of their previous working capacity. The rehabilitation status was measured by taking into consideration whether they were, 'working' 'probably working,' 'Does some work,' 'Probably not working,' and 'Not working'. They assessed 584 consecutive patients visiting the clinic for follow-up and found that 82% of them were within the first three categories ('Working', 'probably working', 'does some work') and were functioning well, while 18% ('Probably not working' and 'not working') were not functioning, and therefore, could not claim to have been rehabilitated.
Nagaswamy et al,[5] carried out a very important assessment of the rehabilitation needs of schizophrenic patients. They interviewed 59 schizophrenic outpatients and their families to assess the subjective rehabilitative needs. They found that 64.4% wanted a job, 54.4% wanted some help for the family. Almost 90% of them desired rehabilitation in one form or another and most exhibited multiple needs, which emphasized the role of multifaceted, comprehensive, aftercare package programs. Even as the need for job as a priority was similar to findings in the west, this population differed by having low priority for social skills training and psycho-social structuring, in contrast to the west.
Channabasavanna,[2] in his editorial, has stated that early attempts at rehabilitation would have long-term benefits for the patients and their families. No treatment of mental disorder can be considered as complete or adequate without giving due consideration to rehabilitation or aftercare services. He has also commented that facilities, such as, pensions and other benefits and compensations that are forwarded to other major physical disorders and mental deficiency are not provided for major mental disorders.
Verma and Shiv[6] reported on the effect of rehabilitation in leprosy patients with psychiatric morbidity. They assessed 100 patients with leprosy, among whom 46 were rehabilitated and were staying in an ashram. Others were staying in a slum. They were assessed using the Goldberg General Health Questionnaire (GHQ) and Indian Psychiatric Interview Schedule (IPIS). They found statistically significant differences on psychiatric morbidity between the non-rehabilitated (85%) and rehabilitated groups (68%).
Gopinath and Rao[7] in their invited review article, have reviewed important world literature regarding psychiatric rehabilitation. They describe the principle, components, and efficacy of various rehabilitation activities. They have discussed the scenario in India and suggested steps to be taken to improve rehabilitation efforts in India.
Kastrup et al.,[8] have studied the psychological consequences of torture and they have described the principles of treatment. They have described a model for rehabilitation of such victims, being followed at their center at Copenhagen.
Mathai et al.,[9] in an unique, but small case control study, tried cognitive re- training of four detoxified male alcoholics and compared it with four controls. At the end of six weeks they found a significant improvement in information processing, memory, and reduction of neuro-pshychological deficits. They concluded that neuropsychological rehabilitation was effective in improving cognitive defects of abstinent alcoholics.
Agarwal[10] in his review of the book, 'Innovation in psychiatric rehabilitation,' published by the Richmond Fellowship Society (India) comments, 'Large rehabilitation facilities may be the only viable option'. He opines that there were many rehabilitative initiatives, but unfortunately most of them have not tried to evaluate their efforts scientifically as well as in economic terms. Ponnuchamy et al.,[11] examined the role of family support groups in psychosocial rehabilitation. They observed that members attending support group meetings, expected to get more information about the illness, to develop skills to cope with problems at home, and to learn skills to deal with the ill person. They concluded that participation in a support group meeting positively affected key variables in the participant's adaptation to mental illness in a relative.
Thara[12] in a commentary has stressed the need for cost-effectiveness studies for rehabilitation. She reports the experience of Schizophrenia Research Foundation (SCARF) in rural areas, where it was found that the most suitable elements of a rehabilitation program were empowering the families and offering simple, culture-specific interventions, such as distribution of livestock and fishing nets.
Kumar et al.,[13] have assessed the prevalence and pattern of mental disability among the rural population in Karnataka. It was a community-based, cross- sectional, house-to-house survey. They used IDEAS, developed by Rehabilitation committee of IPS. They studied one thousand subjects randomly. The prevalence of mental disability was found to be 2.3%. The prevalence was higher among females (3.1%) than among males (1.5%). The prevalence was the highest among the elderly and illiterates.
Suresh Kumar[14] observed that there is a definite limitation to the domains of social functioning, cognitive functioning, and psychopathology in chronic schizophrenia patients who have had no rehabilitation. Vocational rehabilitation significantly improves these limitations, which in turn helps these patients to integrate into the society so as to function efficiently in their roles.
COMMENTS
Although rehabilitation of mentally ill is an essential component of psychiatric management there are very few publications in the Indian Journal of Psychiatry in this area. Although many NGOs are providing services in the area of rehabilitation, the models they follow and clinical benefits of the same are not published for the benefit of the psychiatric community. It is important that such rehabilitation service providers are encouraged to publish their activities. It is heartening that following the effort of the IPS to assess the disability in the mentally ill objectively, the government has extended disability benefits to psychiatric patients too. The reach of these benefits to the needy and their social consequences are yet to be assessed. Of late, there has been an initiative from the government of Karnataka to provide short- term residential care for recovering psychiatric patients. The effectiveness of such programs has to be further explored.
Also the heterogeneous population of India will have multiple unique needs and problems to be addressed. Although all mental health professionals stress the importance of culture-specific rehabilitative measures, the solution provided by them has not been published.
CONCLUSION
There is a gross scarcity of publications in the IJP with respect to the rehabilitation in psychiatry. The mental health professionals need to take lead in publishing rehabilitation efforts or models being practiced by them in different parts of India. The effect of the disability benefits provided by the government needs to be assessed. The indigenous, innovative models followed need to be published.
REFERENCES
1. Bachrach LL. Psychosocial rehabilitation and psychiatry in the care of long term patients. Am J Psychiatry 1992;149:1455-60. 2. Channabasavanna SM. Rehabilitation in psychiatry. Indian J Psychiatry 1987;29:**Pg no missing** 3. Gupta P, Prabhu M, Prabhu GG. Rehabilitation of the chronic psychiatric patient. Indian J Psychiatry 1968;10:157-65. 4. Schmidt KE. A measurement of rehabilitation of psychiatric patients. Indian J Psychiatry 1974;16:140-4. 5. Nagaswami V, Valecha V, Thara R, Rajkumar S, Menon SM. Rehabilitation needs of schizophrenic patients. Indian J Psychiatry 1985;27:213-20. 6. Verma KK, Gautam S. Effect of rehabilitation in the prevalence of psychiatric morbidity among leprosy patients. Indian J Psychiatry 1994;36:183-6. 7. Gopinath PS, Rao K. Rehabilitation in psychiatry: An overview. Indian J Psychiatry 1994;36:49-60. 8. Kastyup M, Lunde I, Ortmann J, Genefke IK. Mental consequences of torture- the method of rehabilitation at a rehabilitation centre at Copenhagen. Indian J Psychiatry 1986;28:225-9. 9. Mathai G, Rao SL, Gopinath PS. Neuropsychological rehabilitation of alchoholics: A preliminary report. Indian J Psychiatry 1998;40:280-8. 10. Agarwal AK. Innovations in psychiatric rehabilitation (Book review). Indian J Psychiatry 2000;42:451. 11. Ponnachamy L, Mathew BK, Mathew S, Uadaya Kumar GS, Kalyan Sundaram S, Ramprasad D. Family support group in psychosocial rehabilitation. Indian J Psychiatry 2005;47:160-3. 12. Thara R. Cost of illness of schizophrenia-perspective from an NGO. Indian J Psychiatry 2005;47:205-17. 13. Kumar SG, Das A, Bhandary PV, Soans SJ, Harsha Kumar HN, Kotian MS. Prevalence and pattern of mental disability using Indian disability evaluation assessment scale in a rural community of Karnataka. Indian J Psychiatry 2008;50:21-3. 14. Sureshkumar PN. Impact of vocational rehabilitation on social functioning, cognitive functioning and psychopathology in patients with dronic schizophrenia. Indian J Psychiatry 2008;50:257-61.
H. Chandrashekar N. R. Prashanth P. Kasthuri R. Madhusudhan Department of Psychiatry, Bangalore Medical College and Research Institute, Bangalore, India 46 Disabilities research in India
H. Chandrashekar, C. Naveen Kumar, N. R. Prashanth, P. Kasthuri
ABSTRACT
The objective of this paper is to review all articles related to psychiatric disability that have been published in the Indian Journal of Psychiatry since its inception till date. We have also added up some more relevant literature in the area of mental disability of Indian psychiatric patients. Finally the article ends up with discussion related to challenges associated with mental disability, persons with Disability Act and future directions in the area of psychiatric disability.
Key words: Disability, IDEAS, mental illness
INTRODUCTION
In the past three decades, the concept of disability has shifted from individual impairment to a more social phenomenon. Thus disability is a complex phenomenon, reflecting an interaction between features of a person's body and features of the society in which he or she lives. In this view, persons with disabilities are seen as being restricted in performing daily activities because of a complex set of interrelating factors, some pertaining to the person and some pertaining to the person's environment and social/political arrangements. The social concept of disability introduces the notion that society has erected barriers, physical or attitudinal, which affect a person with disabilities. Consequently, government programs and policies have evolved to include fixing the environment (e.g., making buildings barrier- free) and providing income assistance or work-related supports to help persons with disabilities participate more fully in the community and the workplace. Even the World Health Organization (WHO) goes beyond a medical approach to take a much broader view of disability. It also recognizes the role environment plays in either facilitating functioning or raising barriers.[1]
It is a well accepted fact that mental illnesses are also associated with a significant disability. Nearly 31% of the world's disability is accounted by mental disorders. It was found that five of the ten leading causes of disability worldwide are in the category of mental illnesses: major depression, alcohol dependence, schizophrenia, bipolar affective disorder and obsessive- compulsive disorder. [2] World health report 2001 by the WHO assessed the leading causes of disability using disability adjusted life years (DALY). Mental illnesses accounted for 25% of total disability and 16 percent of total burden.[3]
Psychiatric disorders, by virtue of their very nature, display different pattern of disabilities when compared to that of physical ailments. It is important to note that social and work related functioning are more important in those with mental illnesses. We also need to remember that mental disability in the form of apathy, amotivation, poor self care communication difficulties and poor inter personal skills are not visible unlike other disabilities, viz. blindness or locomotor disability. There are instances when disability benefits like bus passes were denied because they look physically strong. It is compounded by stigma and discrimination. It is in this context, measures of psychiatric disability have been designed.
Research initiatives in the area of psychiatric disability in India have focused more on schizophrenia. Attention has been given to two important issues: Development or modification of scales for assessments and secondly disability evaluation in persons with chronic psychiatric illnesses. Disability has been assessed in psychiatric patients in different settings such as in hospitals, in community and also in follow-up studies. [2] As early as in 1979, Wig et al.[4] constructed a scale to measure disability of Indian psychiatric patients. They found that psychotics (ICD-8) obtained significantly higher scores than neurotics and persons with greater personal disability accepted treatment more often than those with less personal disability scores.
A decade later, Thara et al.[5] modified the Disability Assessment Schedule (WHO DAS-II) by deleting certain items and regrouping the rest into four main areas of personal, social, occupational and global disability because the DAS II was not entirely culture-free. This modified instrument was developed, validated and called the Schedule for Assessment of Psychiatric Disability (SAPD). They also administered this to 30 patients, each of the three groups of psychoses, neurotics and diabetics. It was found that the SAPD effectively discriminated the psychotic group from the other two groups. The authors recommended this instrument for measurement of disability in out-patient psychiatric population.
Further, Thara and Rajkumar[6] followed up 68 schizophrenia patients prospectively for a period of six years using standardized instruments. Disability was assessed using the SAPD at the end of four, five and six years of follow-up. They found that the three-year course of disability tended to be stable without any fluctuations and that the highest disability was in the area of occupational functioning. Moreover, the disability was not related to the number of relapses. The authors noted that this could be due to the following factors: The cohort was closely followed up and well treated; all patients were started treatment early in the course of their illness.
Shankar et al.[7] reported the gender differences in disability among married patients with schizophrenia. The study sample included 30 married patients of both sexes. Disability was evaluated using the modified version of the Disability assessment schedule. Results indicated that women were more disabled than men, in contrast to the findings from literature elsewhere. Negative symptoms predominated among the factors associated with global disability in both sexes.
Srinivasa Murthy et al.[8] assessed the costs and effects of a community outreach program for untreated schizophrenia patients in a rural community. Hundred cases were recruited and provided appropriate psychotropic medication and psychosocial support. They also assessed every three months over one and a half years on symptomatology, disability, family burden, resource use and costs. Results showed that summary scores of disability along with psychotic symptoms and family burden were all reduced over the follow-up period. These were also accompanied by reductions in the costs of informal-care sector visits and family care-giving time.
Mohan et al.[2] undertook a tertiary hospital-based study to assess and compare disability using the IDEAS in patients with schizophrenia and obsessive-compulsive disorder. They included patients with only mild severity illness. Majority of the schizophrenia patients were from rural areas whereas most of the OCD patients were from an urban background. Patients in both groups had considerable global disability. Understandably, schizophrenia patients had significantly greater disability across all domains of IDEAS. Duration of illness had no effect on disability scores in schizophrenia patients, but it had a negative impact with respect to OCD.
Choudhry et al.[9] assessed some aspects of disability associated with seven psychiatric disorders: Schizophrenia, bipolar affective disorder, anxiety disorder, depression, obsessive-complusive disorder, dementia and mental and behavioral disorders due to the use of alcohol. Their aim was to: Evaluate the nature and quantity disabilities in the study groups, compare the degree of disability with the severity of the disorder, compare disability among various disorders and study the longitudinal stability of disability in the disorder groups. They assessed a total of 228 patients attending the outpatient department of Assam Medical College, Dibrugarh, India, between July 2003 and June 2004. Patients were initially diagnosed using the ICD-10 criteria. Further, for those who consented to participate in the study, interviewers administered schedule for clinical assessment for neuropsychiatry (SCAN). Severity of the disorders was assessed by applying commonly used rating scales for each specific disorder. Disability was assessed using the Indian Disability Evaluation and Assessment Scale (IDEAS). Patients were followed up at six and 12 months. Results showed that all seven disorders studied were associated with significant disability; schizophrenia being maximally disabling. The domains of disability varied across the various disorders studied. The disability tended to correlate with the severity of the disorders. Disability associated with alcohol use disorder and anxiety was comparable to disability due to obsessive-compulsive disorder. Though the follow-up rates were low, analysis of the available data showed that the disability across most disorders reduced at the end of six month follow-up and then tended to even out after that period.
Tharoor et al.[10] cross-sectionally compared the inter-episode quality of life (QOL) and disability of patients with remitted bipolar affective disorder (BAD) or recurrent depressive disorder (RDD) with and without co morbid chronic medical illness. Assessments were carried out on the four subgroups (20 patients in each). QOL assessment was carried out using the World Health Organization (WHO)-QOL-Bref Kannada version and disability was assessed using the schedule for assessment of psychiatric disability (SAPD), which is the Indian modification of the WHO disability assessment schedule-II. In patients who had medical comorbidity, BAD patients were significantly more disabled in 'social role' domain when compared with RDD patients (P 5 0.04); while RDD patients were significantly more disabled in the 'home atmosphere' domain (P 5 0.001). In patients who did not have medical co morbidity, BAD patients were significantly more disabled in the overall behavior domain when compared to RDD patients (P 5 0.002); while RDD patients were significantly more disabled in 'assets and/or liabilities' (P 5 0.004) and home atmosphere (P 5 0.001) domains. The QOL measures did not differ significantly between the two disorders. The authors concluded that the medical illnesses may have a role in increasing disability but less likely to have a significant impact on QOL in mood disorders when patients are euthymic.
Kumar et al.[11] assessed the prevalence and pattern of mental disability in a rural taluk of Karnataka district. This was a community-based cross-sectional study. One thousand subjects were randomly selected from four villages and IDEAS was administered. Overall prevalence of mental disability was 2.3%. Among the disabled, majority had mild disability, followed by severe, moderate and profound severity. All disabled subjects were previously diagnosed with one or the other mental disorder such as: Affective disorders, mental retardation, epilepsy, neurosis, schizophrenia, alcohol addiction.
Krishnadas et al.[12] measured cognitive dysfunction in 25 remitted schizophrenia patients attending a psychiatry unit of a general hospital. Remission was confirmed using the brief psychiatric rating scale (BPRS) and the scale for the assessment of negative symptoms (SANS). The following neurocognitive measures were used: PGI memory scale, Trail making tests A and B, Rey-Osterrieth complex figure test and frontal assessment battery. Disability was assessed using the IDEAS. Results showed that patients had considerable cognitive dysfunction across all measures. Moreover, the authors did not find a statistically significant relationship between cognitive dysfunction and disability scores.
Gururaj et al.[13] assessed the disability along with family burden and quality of life of moderately ill obsessive compulsive disorder (OCD) and compared those with that of schizophrenia patients of comparable severity. Disability was assessed using the WHO-DAS. Results showed that both groups were similar across most domains of disability. The authors concluded that OCD is associated with significant disability often comparable to schizophrenia. Thirthalli et al.[14] assessed disability in 182 community dwelling schizophrenia patients in Thirthalli taluk of Shimoga district of Karnataka using the Indian Disability Evaluation and Assessment Scale (IDEAS). Their aim was to compare disability of schizophrenia patients receiving continuous antipsychotic treatment with that among those who were not taking antipsychotics or taking irregular treatment. Results showed that patients on antipsychotics had significantly less disability across all domains and in total IDEAS scores. Treatment status predicted disability scores even after controlling for the effects of controlling factors like age, sex, education, socio-economic status, duration of illness and alcohol dependence/harmful use. Different levels of exposure to antipsychotics were associated with different levels of disability. Though there was no randomization, this study was conducted with a naturalistic design. The two groups did not differ in any of the clinical or socio-demographic variables. The authors concluded that treatment with antipsychotics is associated with significantly less disability.
Thirthalli et al.[15] compared the course of disability in schizophrenia patients receiving antipsychotics and those remaining untreated in a rural community. Of the 215 patients identified, 58% were not receiving antipsychotics. Trained raters assessed the disability (IDEAS) in 190 of these at baseline and after one year. The course of disability in those who remained untreated was compared with that in those who received antipsychotics. Results showed that in patients who remained untreated, the mean disability scores remained unchanged, but in those who continued receiving treatment and in those antipsychotics were initiated, the scores showed a significant decline (indicating decrement in disability). The proportion of patients classified as 'disabled', declined significantly in the treated group, but remained the same in the untreated group. The authors concluded that treatment with antipsychotics in the community results in a considerable reduction in disability.
Legislation for benefit of disabled persons
India being a signatory to the proclamation adopted in the meeting to launch Asian and Pacific decade of disabled persons 1993-2002 at Beijing from 1st to 5th December, 1992 had to enact a law for the benefit of the disabled. Hence the persons with disabilities (Equal opportunities, Protection of rights & Full Participation) act 1995 was passed in the parliament. Mental illness was included as one of the disabilities. Two important gazette notifications in this regard are:
1. Ministry of Social Justice and Empowerment Notification [Gazette no 49 dated18th Feb 2002] which states that • Mental illness has been recognized as one of the disabilities • Defined as any mental disorder other than mental retardation • A committee was constituted to prescribe guidelines for evaluation and assessment of mental illness (6th Aug 2001).
2. Ministry of social Justice and Empowerment Notification [Gazette No. 49 dated 27th Feb 2002] • Authorities to give certificate will be the medical board constituted by Govt [section (1) and (2) of section 73 of Person with Disability act 1995] • Certificate valid for 5 years or permanent • Director General of Health Services (DGHS) will be the final authority.
Although PDA 1995, defines mental illness as any mental disorder other than mental retardation and includes only persons suffering from more than 40% disability, not all mentally ill are disabled and hence the definition has to be changed. One proposed definition in this regard (amendments proposed to the PDA, 1995)[16] is 'a disorder of mind that results in partial or complete disturbance in the person's thinking, feeling and behavior, which may also result in recurrent or persistent inability or reduced ability to carry out activities of daily living, self-care, education, employment and participation in social life'. It is noteworthy in this context that the notification does not require any psychiatric diagnoses for the purpose of disability. Although a number of tools that measure psychiatric disability existed, there was a need to develop a simple instrument that led to scores and then percentages. Consequently, the Rehabilitation Committee of the Indian Psychiatric Society (IPS) came up with the Indian disability evaluation and assessment scale (IDEAS) in 2002. IDEAS was field tested in nine centers all over India and has now been gazetted by the Ministry of Social Justice and Empowerment, Government of India, as the recommended instrument to measure psychiatric disability (Thara 2005). According to the IPS, only patients with the following diagnoses as per ICD-10 or DSM criteria are eligible for disability benefits: Schizophrenia, OCD, bipolar disorder and dementia.[17]
Government benefits for the disabled include • Travel concession in Railways: 75% concession to the disabled and an accompanying person • Annual passes at concessional rates by the State Road Transport Corporations • Monthly maintenance allowance: Rs 400/- (for persons with disability between 40 and 70%) and Rs 1000/- for those whose disability exceeds 70% • Benefits under various welfare programs like the Rojgar yojanas • Income tax benefits • Family pension: This will be given to the disabled after death of parents • Employment reservation: Three to five per cent jobs in Government are reserved for disabled; Government has also identified jobs for mentally ill in this sector. In this context, it may by noted that the education department in a certain state government has reserved five per cent of its posts for the disabled; of this, one per cent is exclusively reserved for people with mental illness and 1% (only group-D posts) is exclusively for persons with mild levels of mental retardation • Encouragement of students/self employment.
However, the number of patients getting benefits under the disability act is very low because of many barriers as listed below.
Challenges and barriers of disability in mental illness
Attempts to improve the fate of the mentally disabled, especially in developing countries like India, face many obstacles. Stigmatization and discrimination are factors that come in the way of mentally ill receiving full disability benefits. People may have preconceived notions about the mentally ill - that these people are lazy or dangerous. These will have important consequences on how individuals come to see themselves and lowering their self esteem (Self-stigmatization) which may worsen their disability. The levels of knowledge of mental illness do not correlate with discriminatory attitudes. Even a proportion of medical personnel who are well informed are not tolerant towards the mentally ill. Consequences of discrimination include increasing vulnerability to disability, magnifying the impact of illness, depriving care and treatment. There also exist many barriers for the disabled to access the due benefits. These include: Stigma, poor knowledge about the IDEAS, fear of Misuse of Certificates, discomfort to approach government hospitals, time constraints, rigid negative thinking about legal issues, denial of disability, and 'outside' pressure to issue disability certificates.
FUTURE DIRECTIONS AND CONCLUSIONS
The following are a few suggestions: • The disabled should demand benefits; we should remember that family has the prime responsibility to look after disabled and get the benefits due to them • The voice of the disabled needs to be recognized by the government • Strong encouragement and assistance needs to be given to people with mental disability and their representatives to form organizations • Information regarding disability needs to be disseminated far and wide across the country • The attitude of a professional needs to change • Organized monitoring of disability services and benefits disbursed is needed • Lacunae in mental health laws include need to periodically review existing legislation and plan amendments or bring in new legislation from time to time • There needs to be more research on factors associated with disability and psychiatric disorders.
REFERENCES
1. Singh A, Nizamie SH. Disability: The concept and related Indian legislations. Mental Health Reviews. Available from: http://www.psyplexus.com/mhr/disability_india.html [last accessed on 2009 Dec 24]. 2. Mohan I, Tandon R, Kalra H, Trivedi JK. Disability assessment in mental illnesses using Indian disability evaluation assessment scale (IDEAS). Indian J Med Res 2005;121:759-63. 3. World Health Report 2001. Mental health: New understanding, New hope. Geneva: World Health Organization; 2001. 4. Wig NN, Murthy RS, Pershad D. Relationship of disability with psychiatric diagnosis and treatment acceptance patterns. Indian J Psychiatry 1979; 21:355-8. 5. Thara R, Rajkumar S, Valecha V. The schedule for assessment of psychiatric disability - A modification of the DAS-II. Indian J Psychiatry 1988;30:47-55. 6. Thara R, Rajkumar S. Nature and course of disability in schizophrenia. Indian J Psychiatry 1993;35:33-5. 7. Shankar R, Kamath S, Joseph AA. Gender differences in disability: A comparison of married patients with schizophrenia. Schizophr Res 1995;16:17-23. 8. Srinivasa Murthy R, Kishore Kumar KV, Chisholm D, Thomas T, Sekar K, Chandrashekari CR. Community outreach form untreated schizophrenia in rural India: A follow-up study of symptoms, disability, family burden and costs. Psychol Med 2005;35:341-51. 9. Choudhry PK, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2006;48:95-101. 10. Tharoor H, Chauhan A, Sharma PS. A cross-sectional comparison of disability and quality of life in euthymic patients with bipolar affective or recurrent depressive disorder with and without comorbid chronic medical illness. Indian J Psychiatry 2008;50:24-9. 11. Kumar SG, Das A, Bhandary PV, Soans SJ, Kumar HN, Kotian MS. Prevalence and pattern of mental disability using Indian disability evaluation assessment scale in a rural community of Karnataka. Indian J Psychiatry 2008;50:21-3. 12. Krishnadas R, Moore BP, Nayak A, Patel RR. Relationship of cognitive function in patients with schizophrenia in remission to disability: A cross-sectional study in an Indian sample. Ann Gen Psychiatry 2007;30:6-19. 13. Gururaj GP, Math SB, Reddy JY, Chandrashekar CR. Family burden, quality of life and disability in obsessive compulsive disorder: An Indian perspective. J Postgrad Med 2008;54:91-7. 14. Thirthalli J, Venkatesh BK, Naveen MN, Venkatasubramanian G, Arunachala U, Kishore Kumar KV, et al. Do antipsychotics limit disability in schizophrenia? A naturalistic comparative study in the community. Indian J Psychiatry (In Press). 15. Thirthalli J, Venkatesh BK, Kishorekumar KV, Arunachala U, Venkatasubramanian G, Subbakrishna DK, et al. Prospective comparison of course of disability in antipsychotic- treated and untreated schizophrenia patients. Acta Psychiatr Scand 2009;119:209-17. 16. Amendments proposed to the PWD Act by the Ministry of Social Justice and Empowerment. Available from: http://socialjustice.nic.in/disabled/welcome.htm [last accessed on 2010 Jan 1]. 17. The Rehabilitation Committee of the Indian Psychiatric Society. IDEAS (Indian Disability Evaluation and Assessment Scale) - A scale for measuring and quantifying disability in mental disorders. Indian Psychiatric Society, 2002.
H. Chandrashekar C. Naveen Kumar N. R. Prashanth P. Kasthuri Department of Psychiatry BMC and RI, Bangalore, India 47 Indian research on disaster and mental health
Nilamadhab Kar
ABSTRACT
The primary source for this annotation on disaster mental health research is the Indian Journal of Psychiatry. Key words like disasters, earthquake, cyclone, tsunami and flood were searched from its electronic database and relevant articles are discussed. The cross- referenced articles and relevant researches conducted on disasters in India which are published elsewhere were the secondary sources of information. There have been many epidemiological studies and only a few interventional studies on disasters in India. Prevalence figures of psychiatric disorders varied considerably across studies, secondary to nature and severity of disaster, degree of loss, support available and probably also due to the study methodology. Suggestions for intervention included pre-disaster planning, training of disaster workers, utilization of community-level volunteers as counselors, and strengthening existing individual, social and spiritual coping strategies. There is a need for more longitudinal follow-up studies and interventional studies.
Key words: Disaster, India, Mental health, Research
INTRODUCTION
A variety of articles on post-disaster psychiatric research has been published in the Indian Journal of Psychiatry. The relevance of mental health issues following disasters has also been highlighted in many presidential addresses and editorials in recent years.[1-6] It has been acknowledged that India has been traditionally vulnerable to natural disasters on account of its unique geo-climatic conditions. Both natural and manmade disasters occur quite regularly in India, like many in the developing world.[2,5,7] About 60% of the Indian landmass is prone to earthquakes of various intensities; over 40 million hectares are prone to floods; about 8% of the total area is prone to cyclones and 68% of the areas are susceptible to drought.[2]
Recent major natural disasters were Marathwada earth quake (1993), Andhra Pradesh cyclone (1996), Jabalpur earthquake (1997), super cyclone in Orissa (1999), Gujarat earthquake (2001) and tsunami in Tamil Nadu (2004). There have been major industrial accidents like Bhopal Gas tragedy (1984); the effects of which are still being felt. Manmade disasters are common too, like terrorism, communal riots and violence. Recently, the bomb blasts in many Indian cities and terror attack in Mumbai have been extremely traumatic.
The human and economic cost of frequent disasters in India has been colossal.[1,5] It has been highlighted that there is an adverse impact on the mental health of not only the surviving victims but also their relatives, rescuers and disaster workers. Victim groups who are specifically at risk have been identified, e.g. children and adolescents, elderly, those with past psychiatric history etc.[1,3,8]
EPIDEMIOLOGICAL STUDIES
Natural disasters
A study conducted a month after the Latur earthquake found psychiatric morbidity in 59%; posttraumatic stress disorder (PTSD) in 23% and major depression in 21% being the common diagnoses.[9] Another study following Latur earthquake in Marathwada revealed that survivors had PTSD (74%), major depression (89%), generalized anxiety disorder (GAD) (42%) and panic disorder (28%).[1] An Indian Council of Medical Research (ICMR) study in Latur found that 21.5% of adult males in the affected group received a psychiatric diagnosis compared to 13.1% in the controls; corresponding figures for adult females were 14.9% and 5.1% respectively.[10]
The psychiatric sequelae of the Orissa super-cyclone in 1999 suggested that 80.4% of the subjects had probable psychiatric disorder. PTSD was found in 44.3%; anxiety disorder in 57.5% and depression in 52.7%. A considerable proportion (63.4%) of victims with psychiatric disorder had comorbidity. Children and adolescents, elderly persons, lower socioeconomic status (SES), lower educational levels, unemployment, physical injury, degree of exposure, need for evacuation, death in the family, fear of imminent death during the event, hopelessness, increased stress before disaster and past psychiatric history were associated with adverse psychological sequelae. Increase in suicidality was observed.[8]
Around one year after the super-cyclone in Orissa, a study on adolescents found that the prevalence of PTSD was 26.9%, depression 17.6%, and GAD 12.0%. Proportion of adolescents with any diagnosis was 37.9%. Comorbidity was found in 39.0% of adolescents with a psychiatric diagnosis. Adolescents from middle SES were more affected. Prolonged periods of helplessness and lack of adequate post-disaster psychological support were perceived as probable influencing factors other than the severity of the disaster. [11] Another study on children following the super-cyclone, found that PTSD presentations were similar to that in other cultures. It was felt that, though highly prevalent, PTSD might be missed without clinical screening. PTSD was present in 30.6%, and an additional 13.6% had sub-syndromal PTSD. Parents or teachers reported mental health concerns in 7.2% subjects, who were only a minor proportion (12.8%) of subjects with any syndromal diagnosis. Significantly more (43.7%) children in high-exposure areas had PTSD than those (11.2%) in low-exposure areas. Depression was significantly associated with PTSD. High exposure, lower educational level and middle SES significantly predicted PTSD. Extreme fear and perceived threat to life during disaster, death in family, damage to home, stay in shelters were not significantly associated with PTSD in children.[12]
The prevalence rates for psychiatric disorders (27.2%) and psychological symptoms (79.7%) around six to nine months following the tsunami in coastal Tamil Nadu have been considerable. The commonest psychiatric disorder was depression, followed by alcohol use disorders in males and anxiety disorders in females. The rate of PTSD, 12.5/1000, was found to be lower than expected. It was perceived that the psychological symptoms get taken care of by the informal social mechanism and counselors working with non-governmental organizations (NGO) and that the specialist psychiatric services are required for a smaller proportion of populations.[13]
In a study of tsunami-affected males in Kanyakumari, 43% had clinically significant psychological distress, and 31% had very high levels of psychological distress. Individuals with higher frequency of personal prayer, better quality of marital life, job satisfaction were relatively protected; whereas substance abuse and severe disaster experience such as losing a family member were risk factors for severe psychological distress.[14]
Initial assessment in the Andaman and Nicobar Islands during the early phase of the 2004 tsunami disaster revealed 5-8% of the population was suffering from significant mental health problems. The authors expected that the psychiatric morbidity would be around 25-30% in the disillusionment phase. High resilience was seen in the joint family system of the tribal Nicobarese.[15] Psychiatric morbidity in these islands during the first three months following the earthquake and tsunami was significantly more (5.2%) in the displaced population than (2.8%) the non-displaced. The overall psychiatric morbidity was 3.7%. The disorders included panic disorder, unspecified anxiety disorder, and somatic complaints. The existence of an adjustment disorder was significantly higher in the non-displaced survivors. Depression and PTSD were distributed equally in both groups.[16]
The most common psychiatric morbidities in children and adolescents as primary (exposed directly to tsunami and earthquake) and secondary (those with close family and personal ties with primary survivors) survivors in the Andaman and Nicobar were adjustment disorder (13.5%), depression (13.5%), panic disorder (10.8%), PTSD (10.8%), schizophrenia (2.7%), and other disorders (43.2%). Sub-clinical syndrome was present in the majority of the primary and secondary survivors. A majority of survivors required community-based group interventions.[17]
Fire disasters are common in India. A study in a Delhi slum following a fire disaster reported that the prevalence of psychiatric disorders was significantly higher (7.8%) compared to that (2.2%) in the control group; prevalence of psychological ill health was also higher (23.2% vs. 5.0% respectively). The common psychiatric disorders were depression, substance use disorders, GAD and somatoform disorder. Age and participation in relief work were found to be strong predictors and physical injuries were found to be a weak predictor of mental health morbidity.[10]
Following a fire disaster in Bangalore in 1981, 35.8% of the bereaved relatives had psychiatric symptoms requiring treatment.[10,18] In another study, following Mandi Dabwali fire disaster 56% of children had PTSD after two months.[19]
Industrial disasters
A study conducted within three months of the Bhopal gas tragedy yielded a 22.6% prevalence of mental disorders. Most of the patients were females (81.1%), and under 45 years of age (74%). The main diagnoses were anxiety neurosis (25%), depression (20%) and adjustment reaction with predominant disturbance of emotions (16%). Cases of psychosis were rare.[1,20]
In a community-based study of a representative sample of the gas-exposed population, the prevalence of psychiatric morbidity in the exposed population after one and a half years of disaster was found to be significantly higher in comparison to control group (9.4% vs. 2.5%).[10,21]
Manmade disasters
Following the Mumbai riots in 1992-93 a study on hospital ized victims found them in a state of shock, fear and helplessness; 33% expressed anger; 2% of these (all female who saw the mangled bodies of their husbands) had attempted suicide; 21% of those interviewed had severe anxiety, 41% had paranoid thinking and obsessional symptoms and majority had loss of libido. PTSD features scored very high; and a few were emotionally dumb; and 36% had suicidal thoughts.[1,22]
Within days of a bomb blast (1996) in a bus in a terrorist activity in Dausa, Rajasthan 35.5% had psychiatric morbidity: 19.4% had acute stress reaction, 9.7% had depression and 6.5% dissociative amnesia. The most commonly reported symptoms were depersonalization, derealization, sleep disturbances, specially generalized sleep loss, loss of appetite, nightmares, situational anxiety, depression, mental irritability, dullness of feelings, self blame, guilt, loss of interest, suicidal ideas, and worry about money, spouse, work and children.[23]
Four years after exposure to communal violence in Ahmedabad PTSD was found in 4.7% of children and adolescents; and 9.4% had major depression. PTSD was associated with age older than 12 and residence in Ahmedabad, the worst affected city; it was not associated with gender, religion, change of residence, income or education.[24]
Other studies
A study explored the experiences of women who were traumatized by the communal riots in Ahmedabad, in 2002. Victims described experiences that closely resembled re-experiencing, avoidance and hyperarousal. The authors concluded that PTSD may be a relevant clinical construct in the Indian context.[25]
The challenges in diagnosing PTSD in children have been highlighted in a communiqué observing the differences in trauma responses in children compared to adults, paucity of literature on these from developing countries, complicating post-disaster situations with grief reactions, survivor guilt and trauma-induced demoralization and associated comorbidities. The authors suggested use of semistructured interview schedules, self/parent report instruments, play and projective psychological tests, spending adequate time with children to elicit symptoms of PTSD.[26]
A study looked into neurocognitive function in methyl isocynate (MIC)- exposed women who were affected by the Bhopal gas disaster and compared it with those of normal control using PGI-Battery of Brain dysfunctions. The result suggested that the MIC-exposed women had significant neurocognitive dys functions compared to controls in immediate recall, visual retention, and in results of Nahar-Bensen and Bender-Gestalt tests.[27]
Post-disaster Interventions
Mental healthcare for the disaster-affected populations is viewed in the domain of public mental health whose importance is growing in India.[6] The role of psychiatrists in disaster management has been stressed.[4]
There has been a national initiative for disaster management; however, the need for involvement of mental health professionals in these has not been highlighted; indeed crisis management and psychosocial care have not been adequately recognized in the mainstream disaster management work. The poverty of administrative response to include mental healthcare in disaster management planning and work has also been mentioned.[1] Governments everywhere measure the magnitude of disasters by estimating loss in terms of lives and money. Relief agencies are mainly concerned with providing for physical needs and attending to physical injuries. It has been stressed that the emotional injuries also need caring otherwise they can predispose a large number of victims of disasters to long-term mental health sequelae.[7] The Indian Psychiatric Society has a taskforce on disaster management,[2] which is best placed to influence the national strategy to include mental healthcare for disaster victims.
Many authors in the Indian Journal of Psychiatry have suggested interventional methods for the disaster victims. Highlighted are the concepts like prevention of psychological disorders, preparedness, organization of mental health teams at disaster sites, prioritizing care for the groups with higher risk, rehabilitation, involvement of local individuals and organizations in post-disaster psychosocial work and training the primary care health professionals to provide mental healthcare.[1,28] It has been emphasized that disaster-related mental health issues need phase-appropriate responses and interventions, considering the five conceptual phases, namely: pre- disaster warning phase; disaster phase: during and immediately after the disaster; early; recent; and remote post-disaster phases.[29,30]
In an interesting article published in 1963, psychiatric 'First Aid' in community disasters has been discussed with specific reference to nuclear warfare.[31] It is noted that 'human kindness and generosity are seen in abundance towards those afflicted by any disasters, but rarely is the mind of the injured person considered from the scientific and professional aspects when first aid is thought of and administered'. It was predicted that more than 50% of the large number of casualties of war will be psychiatric in nature. The article emphasized the need for psychiatric First Aid to deal with these cases effectively. It has described various effects of war trauma from normal reactions to panic, depressed, hyperactive, somatic, psychotic and delayed reactions and the nature of First Aid for these. It briefly mentions the predisposing factors and mechanisms for 'breakdown'.
Suggested methods of First Aid included: prompt and firm support, personal attention to make the victim feel less desolate, quiet supervision, suggestion to carry out simple routine tasks of helping others less fortunate than themselves, simple explanations, reassurance, explanation to make the victim understand that regardless of the cause of the disaster the damage must be repaired by coordinated effort by all available personnel. For psychotic reactions, the author mentioned that these were usually short-lived being known as 'three-day psychoses' which might disappear with removal from the traumatic situations, however, sometimes sedation and Electroconvulsive therapy (ECT) might be advisable, if other methods did not work.[31]
Psychological First Aid has also been stressed in a dedicated editorial on the mental health perspective of disaster. [5] It describes debriefing and defusing, crisis reduction counseling, crisis intervention in post-disaster situation. This article also suggests preparing the disaster personnel in crisis intervention and emergency management during the pre-disaster planning. Factors influencing recovery have been highlighted.
In India a wide range of non-specialist personnel as well as volunteers discharge a wide variety of mental healthcare tasks including those following disasters.[28] It has been suggested that the disaster mental health teams must be able to understand the local culture, traditions, language, belief systems and local livelihood patterns to respond to a high-magnitude disaster. They also need to integrate with the network of various relief agencies to cater to the needs of the survivors. The presence of a disaster mental health team is considered as a definite requirement during the early phase of the disaster in developing countries. [15] It has been reported that community-based group interventions are simple, easy to implement using local resources, effective in all groups and provide important components of psychosocial rehabilitation. There are many examples of this kind of intervention following disasters, in the Indian setup.[8,17,32]
An intervention program for children a year after tsunami found that, only hyperactivity problems were significantly reduced after intervention. Children in the intervention group appreciated expression of positive emotions and were also more likely to desist from smoking compared to the control group. The majority of the children were likely to be resilient and only children with preexisting vulnerability required specific and specialized interventions.[33]
A qualitative study through focus group discussions nine months after the tsunami in Tamil Nadu reported that participants reconstructed meaning for the causes and the aftermath of the disaster in their cultural idiom. Qualitative changes in their social structure, processes and attitudes towards different aspects of life were revealed. Survivors valued their unique individual, social and spiritual coping strategies more than formal mental health services. The results of this study suggested that interventions after disaster should be grounded in ethno-cultural beliefs and practices and should be aimed at strengthening prevailing community coping strategies.[34]
An experiential account of mental healthcare following the devastating earthquake of Latur is worth mentioning. A mental health camp was set up in a temple by a group of psychiatrists. The author writes, "We had just begun our 'funda' with our PTSD business, when the villagers cracked a joke on their own. As they continued, the session became hilarious and we fulfilled our agenda. The fantastic component was that the villagers set the agenda and the method of healing through their own cultural and mental processes." This observation highlights many important aspects of mental healthcare in a disaster-affected community. He reflects, "The mantra for disaster worker is that when a survivor initiates laughter, go with it but do not jump on the bandwagon and be a driver. Let him/her be and you gently nudge the process with all participants as partners in the process".[35] The above reaffirmed the healing elements of humor; however, being able to utilize it in post-disaster situations could be a tough task.
There are a few other researches and observations on disasters in India published elsewhere which can be used as additional sources of information on this subject.[36,37,38,39,40]
CONCLUSIONS
There is a great need for long-term prospective studies on the effects of disaster and more interventional studies to find out the effectiveness of supportive measures provided to the victims. Factors that can prevent psychiatric morbidity in the survivors need to be ascertained. It is imperative to inculcate a mental health support system in the disaster response strategies in India.
ACKNOWLEDGMENT
Quality of Life Research and Development Foundation REFERENCES
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Am J Psychiatry 1996;153:556-8. 10. Desai NG, Gupta DK, Srivastava RK. Prevalence, pattern and predictors of mental health morbidity following an intermediate disaster in an urban slum in Delhi: A modified cohort study. Indian J Psychiatry 2004;46:39-51. 11. Kar N, Bastia BK. Post-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: A study of comorbidity. Clin Pract Epidemiol Mental Health 2006;2:17. 12. Kar N, Mohapatra PK, Nayak KC, Pattnaik P, Swain SP, Kar HC. Post-traumatic stress disorder in children and adolescents one year after a super-cyclone in Orissa, India: Exploring cross-cultural validity and vulnerability factors. BMC Psychiatry 2007;7:8. 13. Nambi S, Desai NG, Shah S. Mental health morbidity and service needs in tsunami affected population in coastal Tamil Nadu. Indian J Psychiatry 2007;49:S2-3. 14. George C, Sunny G, John J. Disaster experience, substance abuse, social factors and severe psychological distress in male survivors of the 2004 tsunami in South India. Indian J Psychiatry 2007;49S:47. 15. Math SB, Girimaji SC, Benegal V, Uday Kumar GS, Hamza A, Nagaraja D. Tsunami: Psychosocial aspects of Andaman and Nicobar islands. Assessments and intervention in the early phase. Int Rev Psychiatry 2006;18:233-9. 16. Math SB, John JP, Girimaji SC, Benegal V, Sunny B, Krishnakanth K, et al. Comparative study of psychiatric morbidity among the displaced and non-displaced populations in the Andaman and Nicobar Islands following the tsunami. Prehosp Disaster Med 2008;23:29- 34. 17. Math SB, Tandon S, Girimaji SC, Benegal V, Kumar U, Hamza A, et al. Psychological impact of the tsunami on children and adolescents from the andaman and nicobar islands: Prim Care Companion J Clin Psychiatry 2008;10:31-7. 18. Narayanan HS, Sathyabati K, Nardev G, Thakar S. Grief reaction among bereaved relatives following a fire disaster in a circus. NIMHANS J 1987;5:13-21. 19. Sharma A, Rao S, Srinivas S. Mandi Dabwali fire disaster. Psychological impact on school children after two months-preliminary findings. Indian J Psychiatry 1998;40S:51-2. 20. Murthy RS. Psychological consequences of Bhopal disaster. In: Proceedings of National workshop on psychosocial consequences of disasters. Bangalore: NIMHANS; 1997. 21. Bhiman A. Mental health consequences of Bhopal gas tragedy. Paper presented in the 17th World Congress of Social Psychiatry, Agra: 27-31 October 2001. 22. Shetty H and Chhabria A. Bombay riots. In Proceedings of National workshop on Psychosocial consequences of disasters. Bangalore: NIMHANS; 1997. 23. Gautam S, Gupta ID, Batra L. Sharma H, Khandelwal R, Pant A. Psychiatric morbidity among victims of bomb blast. Indian J Psychiatry 1998;40:41-5. 24. Vankar GK, Banwari G, Parikh V, Shah H. PTSD in children and adolescents: Four years after the communal violence. Indian J Psychiatry 2007;49S:4. 25. Mehta K, Vankar G, Patel V. Validity of the construct of post-traumatic stress disorder in a low-income country: Interview study of women in Gujarat, India. Br J Psychiatry 2005;187:585-6. 26. Murali N, Kar N, Jagadisha. Recognition and clinical assessment of childhood PTSD. Indian J Psychiatry 2002;44:82-3. 27. Sahu RN, Naik GP, Dusad A, Agrawal VK. Neurocognitive function in women affected by the Bhopal gas disaster. Indian J Psychiatry 2005;47:51-3. 28. Murthy RS. Introduction to psychiatry: Book Review. Indian J Psychiatry 2009;51:72. 29. Kar N. Psychosocial issues following a natural disaster in a developing country: A qualitative longitudinal observational study. Int J Disaster Med 2006;4:169-76. 30. Kar N, Misra BN. Mental health care following disasters. Bhubaneswar: Quality of Life Research and Development Foundation; 2008. 31. D'Netto TB. Psychiatric first aid in community disasters, with special reference to Nuclear warfare. Indian J Psychiatry 1963;3:176-80. 32. Vijaykumar L, Thara R, John S, Chellappa S. Psychosocial interventions after tsunami in Tamil Nadu, India. Int Rev Psychiatry 2006;18:225-31. 33. Vijayakumar L, Kannan GK, Ganesh Kumar B, Devarajan P. Do all children need intervention after exposure to tsunami? Int Rev Psychiatry 2006;18:515-22. 34. Rajkumar AP, Premkumar TS, Tharyan P. Coping with the Asian tsunami: Perspectives from Tamil Nadu, India on the determinants of resilience in the face of adversity. Soc Sci Med 2008;67:844-53. 35. Shetty H. Awakening the kundalini of humour. Indian J Psychiatry 2006;48:267-71. 36. Murthy RS, Isaac MK. Mental health needs of Bhopal disaster victims and training of medical officers in mental health aspects. Indian J Med Res 1987;86:51-8. 37. Murthy RS, Kar N, Sekar K, Swain S, Mishra V, Daniel U. Evaluation report on psychosocial care of survivors of supercyclone in Orissa. Bhubaneswar: Sneha Aviyan, Action Aid; Bangalore: NIMHANS; 2003. 38. Rao K. Lessons learnt in mental health and psychosocial care in India after disasters. Int Rev Psychiatry 2006;18:547-52. 39. Shethi BB, Sharma M, Trivedi JK. Singh H. Psychiatric morbidity in patients attending clinics in gas affected areas in Bhopal. Indian J Med Res 1987;86S:45-50. 40. Shetty H. Marathawada earthquake. In: Proceedings of National workshop on Psychosocial consequences of disasters. Bangalore: NIMHANS; 1997.
Nilamadhab Kar Department of Psychiatry Mental Health Directorate Wolverhampton City PCT Wolverhampton, UK 48 Indian research on suicide
Lakshmi Vijayakumar
ABSTRACT
The suicide rate in India is 10.3. In the last three decades, the suicide rate has increased by 43% but the male female ratio has been stable at 1.4 : 1. Majority (71%) of suicide in India are by persons below the age of 44 years which imposes a huge social, emotional and economic burden.
Fifty four articles on suicides have been published in IJP. Several studies reveal that suicidal behaviours are much more prevalent than what is officially reported. Poisoning, hanging and self immolation (particularly women) were the methods to commit suicide. Physical and mental illness, disturbed interpersonal relationships and economic difficulties were the major reasons for suicide. The vulnerable population was found to be women, students, farmers etc.
A social and public health response in addition to a mental health response is crucial to prevent suicidal behaviour in India.
Key words: Suicide, India, Risk factors
INTRODUCTION
More than one lakh lives are lost every year due to suicide in India. In the last three decades (from 1975 to 2005), the suicide rate increased by 43%. The rates were approximately the same in 1975 and 1985; from 1985 to 1995 there was an increase of 35% and from 1995 to 2005, the increase was 5%. However, the male-female ratio has been stable at around 1.4 to 1. There is a wide variation in suicide rates within the country. The southern states of Kerala, Karnataka, Andhra Pradesh and Tamil Nadu have a suicide rate of .15 while in the Northern States of Punjab, Uttar Pradesh, Bihar and Jammu and Kashmir, the suicide rate is ,3. This variable pattern has been stable for the last 20 years. Higher literacy, a better reporting system, lower external aggression, higher socioeconomic status and higher expectations are the possible explanations for the higher suicide rates in the southern states (Vijayakumar L, 2008).[1]
Majority of the suicides (37.8%) in India are by those below the age of 30 years. The fact that 71% of suicides in India are by persons below the age of 44 years imposes a huge social, emotional and economic burden on society.
The near equal suicide rates of young men and women and consistently narrow male:female ratio denotes that more Indian women die by suicide than their Western counterparts. Poisoning (34.8%), hanging (31.7%) and self- immolation (8.5%) were the common methods used to commit suicide (accidental deaths and suicide 2007).[2] Two large epidemiological verbal autopsy studies in rural Tamil Nadu reveal that the annual suicide rate is six to nine times the official rates. If these figures are extrapolated it suggests that there are at least half a million suicides in India every year. It is estimated that one in 60 persons are affected by suicide. It includes both, those who have attempted suicide and those who have been affected by the suicide of a close family or friend. Thus, suicide is a major public and mental health problem which demands urgent action.
Fifty four articles on "Suicide" have been published in the IJP from 1958 to 2009. The relative paucity in publications can be attributed to several factors but chiefly to the fact that it is an extremely difficult area to take up for research considering its sensitive nature, associated stigma and legal implications. It is interesting to note that the first article on attempted suicide appeared only in 1965. The articles ranged from references to suicide in ancient literature to psychobiological variables in suicide, epidemiological studies to prevention strategies.
The publications have been categorized under (1) Incidence and prevalence studies (2) Profiling and identification of risk factors (3) Suicide and suicidal behavior in specific communities (4)Studies on Non Fatal Deliberate Self Harm (DSH) (5) Suicide prevention strategies (6) and other, suicide related publications. The segregation is for the sake of convenience alone and should not be seen as being exclusive to its allocated category.
There have been four studies from abroad published in the IJP that have not been covered in the present review, these comprise of a study on women from Trinidad and Tobago, a study from US on adolescence, on teenage suicide attempters from UK and a Japanese study on pesticide suicides.
INCIDENCE AND PREVALENCE STUDIES
There have been several studies reporting the incidence of suicide in India. Over the years the studies have reported incidence rates ranging from 2.36 to 42 per 100,000 populations. The majority of these have been hospital based studies along with a few community based samples.
In one of the first article on attempted suicide published by the IJP, Venkoba Rao[3] reported an incidence rate of 43 / 100,000 in Madurai. He also reported that 1 in 12 cases of suicide attempts were fatal.
Nandi et al.[4] studied incidence rates in Bengal using data available in the public domain across a hundred year period (1872-1972) and reported that the incidence of suicide had increased significantly from 2.36/100,00 in 1872 to 15.96 in 1972. The study also revealed that there was preponderance of male suicides, the vulnerable age group being those between the ages of 18 to 30 and the most common method employed was poisoning.
Hedge[5] in his study on the patterns of suicide in a rural community in northern Karnataka reported an incidence rate of 9.3/100,000. The study also reported a male (67%) preponderance. The study also revealed that rural suicide patterns did not vary from urban.
In contrast to these reports Shukla et al.[6] in their study on the incidence of suicides in Jhansi city reported more suicides among women (34 / 100,000) than men (24 / 100,000). Several other gender related differences were also reported, women were significantly younger (24.6 years) compared to the men (28.9 years), self immolation was the most frequent method of suicide by women while for men it was being run over by a train. Domestic strife and mental illness were identified as the most common causative factors. The study reported an incidence rate of 29/100,000.
These findings were supported by Banarjee et al.[7] who studied the vulnerability of Indian women. They found that the incidence of suicide was 43/100,000 in Bengal and that women (79.3%) outnumbered men. 75% of the victims were below 25 years of age and the commonest cause for suicide in women was quarrel with husband, while in men it was with parents. Ingestion of insecticide was the most common method of committing suicide.
PROFILING AND IDENTIFICATION OF RISK FACTORS
Majority of the published studies on suicide have dealt with identifying the socio-demographic and psychosocial aspects of suicide attempters and those who have completed suicide. Some of these have also attempted to identify the characteristic differences between the two groups. Most of these were hospital based studies. The study methods used varied, from use of psychological autopsies to interviews to perusal of records. Venkoba Rao[3] in his hospital based study on suicide attempts reported a preponderance of males and identified the vulnerable age group as being those from 15 to 25 years. Lack of social cohesion was identified as a significant risk factor. 20% of the attempters also had a family history of mental illness/suicidal attempts. The method of attempting suicide as well as the time (during daytime or night), were not seen as factors influencing intent.
In another hospital based study Lal and Sethi[8] reported that women attempted suicide more often, were below 30 years of age, were housewives or domestic help, married and income levels of 83.4% was less or equal to Rs. 200 per month. Females with lower educational level and joint families and males with higher educational levels and from unitary families attempted suicide more frequently. Similarly, a study by Badrinarayana[9] also revealed that younger people (age range of 10 to 30 years) were more likely to attempt suicide. The primary causes were identified as Mental illness and disturbed interpersonal relationships. Extramarital affair was also identified as a risk factor for a spouse to attempt suicide by Venkoba Rao.[10]
Nandi et al.[11] investigated the relationship between availability of lethal insecticide and the incidence of suicide. The study concluded that there was no association between the easy availability of the lethal insecticide and the high incidence of suicide but rather it was the motive which actually determines the incidence of suicides.
Bagadia et al.[12] attempted to examine the relationship between unemployment and suicide and concluded that though unemployment may be an important factor in suicide it did not appear to be the causative factor. The study postulated that both unemployment and suicidal behavior could be due to some common psychopathological factors. However, Srivatsava et al.[13] (2004) identified unemployment, presence of a stressful life event in the last six months, suffering from physical disorders and having idiopathic pain as definite risk factors for attempting suicide.
In their study from Ludhiana, Narang et al.[14] reported that single males and married females were more likely to attempt suicide. They, however, did not find type of family, economic status and educational levels as being significant variables. Mood disorders and adjustment disorders were diagnosed in a significant number of them.
Bagadia et al.[15] conducted a study on 521 patients admitted for suicidal behavior and reported that the degree of intent was low, duration of suicidal ideas ranged from more than 1 year (2%) to it being an impulsive act in 17% of them, 18% communicated about the attempt while the majority of women (76.1%) attempted suicide in the presence/proximity of others. Previous attempts were reported in 7% with 2.4% having more than one previous attempt. Depression (39.73%), schizophrenia (24.4%) and hysteria (14%) were the most common psychiatric diagnosis made.
These findings were also confirmed by Gupta and Singh[16] who reported psychiatric disorders in 62% with 58% having abnormal personalities. Mahla, et al.[17] investigated attempted cases of self immolation and reported that the behavior was associated with the presence of psychiatric and personality disorders. Jain, et al.[18] also found that 37.5% of the suicide attempters had a diagnosis of depression, 39.28% of the subjects showed mild to moderated suicidal intent and 16% of them had a high score on the hopelessness variable. Similarly, in their study using the method of psychological autopsy, Khan, et al.[19] identified the presence of psychiatric illness and stressful life events as the two most important reasons for completing suicide.
Badrinarayana[20] found a positive and significant correlation between depressive illness, suicidal ideation with early parental deprivation, recent bereavement and positive family history of suicide. Similarly Srivastava and Kulshreshtha[21] reported a positive correlation between severity of depression, being married, being employed, being male, prior history of treatment in a mental hospital setting, more than a month's duration of illness and age being less than or equal to 35 years.
Anand, et al.[22] in their study on suicidal intent identified three distinct groups comprising of non communicators (31.9%), partial communicators (32.6%) and definite communicators (35.5%). A study by Ponnudurai et al.[23] revealed that 23.25% had contemplated suicide earlier and that 91.9% of them were aged 30 years or less. A strong association with alcohol was reported in 10.42% of the sample.
In his comparison study between suicide attempters and completers, Suresh Kumar,[24] reported that those who completed suicide were significantly younger, they were more frequently unemployed and used more lethal methods (hanging) than those who attempted. Other variables such as religion, domicile, marital status and education showed no difference.
Very few studies pertaining to the biology of suicides have been published in the IJP. The earliest article published was by Devi and Rao,[25] who studied the association between suicide attempts and menstrual cycles. The study reported that women in their pre-menstrual/early menstrual phase (64%) were more vulnerable. Marital status of the patients did not contribute to any heightened vulnerability during premenstruum and menstruation. Palaniappan, et al.[26] explored the possible association between suicidal ideation and biogenic amines. They observed that the levels of 5 HIAA and Serotonin (5HT) were inversely related to suicidal ideas. Rao and Devi[27] in their article state that evidence from genetic research, mono amine studies and psychopharmacological research points towards a possible biological predisposition and precipitant for suicidal behavior.
SUICIDE AND SUICIDAL BEHAVIOR IN SPECIFIC COMMUNITIES
There have been several studies which focus on vulnerable populations and high risk populations including students, the aged, women, armed forces, farmers, migrant populations and those with chronic physical and mental illness.
Venkoba Rao,[28] in his article on attempted suicide among students, reported that during a 10-month period 35 students had attempted suicide, of which seven proved fatal. The most common mode was insecticide ingestion. There were more male students (19) than female (16), most were aged between the ages of 16 to 30 and majority of them were students of Arts and Sciences. Eight of them had attempted suicide previously. No intellectual sub-normality was reported in the sample.
In an another study on the psychosocial and clinical factors associated with adolescent suicidal attempts Kumar, Sudhir et al.[29] compared potential risk factors between adolescent and adult suicide attempters and found that the adolescents had significantly higher levels of depression, hopelessness, lethality of event, and stressful life events. Sharma, et al.[30] in their study on adolescent students found the prevalence of suicide risk behavior quite high with almost 16% having suicide ideation and 5% having attempted suicide. Females were seen as being more vulnerable. The presence of role models who were seen drinking and smoking was seen as increasing the risk behavior.
Rao Venkoba,[31] studied depression and suicidal behavior in the aged and reported that the risk of completed suicide among the aged attempters is twice that of the younger generation. He also identified lack of social integration rather than social isolation per se as the factor causing depression in the aged.
In a study on 100 female burns cases admitted at the Madurai Medical college Venkoba Rao, et al.[32] reported that that 70% of them were suicidal attempts, 25% were accidental, 3% were homicidal and 2% were non classifiable. The most common reasons for suicidal attempts were marital and interpersonal problems followed by psychiatric and physical illnesses respectively. Jacob, et al.[33] in their comparative study on subjects with seizure disorder and bronchial asthma found that 34% of the epilepsy group had a diagnosis of major depressive disorder as compared to 13.3% of the asthma group. Sixteen per cent of the epilepsy group had a history of at least one suicidal attempt in the previous year and 20% of the group expressed current suicidal ideation.
In a study on terminally ill cancer patients Latha and Bhat[34] examined the prevalence of suicidal ideation and reported that only 9.2 % had severe suicidal ideations. 3.8% of the patients with suicidal ideation had a past history of major depression. Factors such as presence of pain, awareness of diagnosis, and understanding of the illness contributed to the depressive states. The study concluded that suicidal ideation and desire for death appeared to be linked exclusively to the presence of a psychiatric disorder.
Satyavati[35] investigated attempted suicides in psychiatric in patients and reported that during a one year period out of 1881 admissions 126 had made suicidal attempts with drowning being the most commonly employed method. Patients with schizophrenia accounted for 64% of the attempted suicides. Gupta, et al.[36] in their two-year follow-up study of patients who had attempted suicide with schizophrenia and depression reported that 51.8% of the suicide attempters had a personality disorder, 42% had neurotic symptoms during childhood and 23.5% had a history of drug dependence. During the follow-up period 17.1% of the schizophrenia patients had attempted suicide again with one completing suicide, compared to 19% of the depressed patients.
Srivatsava and Kumar[37] in their study on patients with major depressive disorder reported that the 17% in patients with suicidal ideation attempted suicide, The risk factors identified were being below 30 years of age, having higher education, being a single male or a married woman or a student. Suicide attempters also had more suicidal ideation, agitation and paranoid symptoms.
In a study on the armed forces Goel[38] argued that suicidal attempts do not constitute a major health concern in the army and that being in the army does not make the individual more vulnerable than the general population to suicide. Chakraborthy[39] in his study reported that the age of suicide attempters in the Army in India was higher than those reported from western countries. Isolation and inability to form relationships were identified as important factors in the suicidal attempts.
The need to focus on migrants as a specifically vulnerable group was brought out by the study of Chavan, et al.[40] who used psychological autopsies to reveal that almost 58% were migrants from other parts of India, were frequently male and young (age 20 to 28 years). Hanging was the most commonly used method for committing suicide. Psychosocial stressors were found in 61% and psychiatric illness was found in 34%. Only 16% had sought treatment prior to their attempt
On a study on farmer suicides in the Vidarbha region, Behere and Behere[41] employed the psychological autopsy method to understand the phenomenon and have identified the following reasons for farmer suicide (1) chronic indebtedness and inability to pay debts accumulated over the years (2) economic decline that leads to complications, family disputes, depression, alcoholism, etc. (3) compensation following suicide helps the family repay debts (4) grain drain and (5) rising costs of agricultural inputs and falling prices of agricultural produce.
STUDIES ON NON FATAL DELIBERATE SELF HARM
Sethi, et al.[42] studied 75 patients admitted for self destructive behavior and found that majority of them belonged to unitary family set up, were unmarried males and almost 15% of them had history of previous suicidal attempts. Financial stress, rejection in love and strained familial relationships were the most common causes.
Sarkar et al.[43] attempted to present a profile of those who commit DSH in comparison with those who expected to die after the suicide attempt. Those attempting DSH were younger, chose less lethal methods to attempt suicide, were more impulsive and had strong histrionic and unstable traits in personality and had an absence of a family history of suicide attempts.
Das, et al.[44] in their study on subjects with intentional self harm attempts reported that the majority of the subjects were married, educated beyond matriculation, were employed or retired, belonged to a nuclear family, were of a middle socio economic status, and came from an urban background. The most common reasons for the attempt were interpersonal problems with family members and spouse. The most common mode was consumption of insecticides followed by use of corrosives. The most common psychiatric diagnosis in the group was depression. The use of organophosphorous pesticide poisoning for DSH was also reported by Chowdhury et al.[45] who found it the most commonly used method.
In their study on non fatal deliberate self harm attempters, Chowdhury et al.[46] identified women exposed to domestic violence as a vulnerable group. They were generally below 30 years of age, married and with low education, Pesticide poisoning was the commonest mode of DSH attempt. Marital conflicts, conflicts with in-laws were the typical stressors. Majority of them experienced more than one form of domestic violence. The study concluded that stressful life situations along with easy availability of pesticides facilitated self harm behavior.
SUICIDE PREVENTION STRATEGIES
There have been very few articles that have dealt exclusively with suicide preventive strategies or with a scientific and systematic evaluation of a strategy.
Singh[47] in his article evaluated the various suicide prevention activities such as the community activities, the psychiatric and medical activities, suicide prevention centers, psychiatric emergency services, crises intervention centers, role of general practitioners, research and media. He concluded by stressing on the role of the psychiatrist in dealing with this issue.
Venkoba Rao[48] in his article delineated the risk factors associated with suicidal attempts and its association with psychiatric disorders and the biological evidence for suicidal behavior. The article based on cited studies recommended that education of general physicians, limiting access to availability of antidepressants, paracetemol and pesticides would lower the rates of suicide.
Jena and Siddharta[49] reviewed articles on non fatal suicidal attempts of adolescents in both Indian and international literature. They stated that non fatal suicidal behavior among adolescents needs to be evaluated and managed effectively in order to reduce the rates. They concluded that Indian studies in this area are a very few and there is a great need to conduct research in this area. The article also stresses the importance for professionals like general practitioners, teachers, pediatricians, school counselors to be trained to identify non fatal suicide behaviors in adolescents so as to facilitate referral and effective management.
Vijayakumar[50] in an editorial expresses the urgent need for suicide prevention in India and stresses that suicide is a multifaceted problem and hence suicide prevention programs should also be multidimensional. Collaboration, coordination, cooperation and commitment are needed to develop and implement a national plan, which is cost-effective, appropriate and relevant to the needs of the community. In India, suicide prevention is more of a social and public health objective than a traditional exercise in the mental health sector. She concludes by saying that the time is ripe for mental health professionals to adopt proactive and leadership roles in suicide prevention and save the lives of thousands of young Indians. OTHER SUICIDE RELATED PUBLICATIONS
Gupta, et al.[51] published an article on the development of a 10 item suicidal intent questionnaire. The article established that the questionnaire was fairly valid but stated that further work was necessary to establish its statistical validity and reliability.
Somasundaram et al.[52] in their paper described the presence of suicide behavior as found in 'Purananuru' an ancient Tamil classic from the 'Sangham' period. The article documents the self immolation of Perun Koppendu on the death of her husband, the fast unto death of a Cheran king in response to being insulted by guards and suicides of important kings and poets because of bereavement. The influence of religion and other cultural beliefs and its influence on perceptions of suicide and its representation in popular culture with specific referenced Tamil literary classics has been brought out in this article.
CONCLUSION
A social and public health response to suicide is crucial in India, and should complement a mental health response. Mental illness is a risk factor for suicide, in India, as it is in developed countries. However, additional risk factors are prominent in India. These tend to relate to societal structures and specific stressors. A social and public health approach acknowledges that suicide is preventable, and promotes a framework in integrated system of interventions across multiple levels within society including the individual, the family, the community, and the health care system. A key step in such an approach involves modifying attitudes toward suicide via educational efforts and legal levers (e.g. decriminalizing suicide).
REFERENCES
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Marriage, parenthood, sex and suicidal behavior. Indian J Psychiatry 1974;16:92-4. 11. Nandi DN, Mukherjee SP, Banerjee G, Ghosh A, Boral CG, Chowdhury A, Bose J. Is suicide preventable by restricting the availability of lethal agents? A rural survey of West Bengal. Indian J Psychiatry 1979;21:251-5. 12. Bagadia VN, Ghadiali HN, Shah LP. Unemployment and attempted suicide Indian J Psychiatry 1976;18:131-9. 13. Srivastava MK, Sahoo RN, Ghotekar LH, Dutta S, Danabalan M, Dutta TK, Das AK. Risk factors associated with attempted suicide. Indian J Psychiatry 2004;46:33-8. 14. Narang RL, Mishra BP, Mohan, Nitesh. Attempted suicide in Ludhiana. Indian J Psychiatry 2000;42:83-7. 15. Bagadia VN, Abhyankar RR, Shroff P, Mehta P, Doshi J, Chawla P, et al. Suicidal behavior: A clinical study. Indian J Psychiatry 1979;21:370-5. 16. Gupta SC, Singh H. Psychiatric illness in suicide attempters. Indian J Psychiatry 1981;23:69- 74. 17. Mahla VP, Bhargava SC, Dogra R, Shome S. The psychology of self immolation in India. Indian J Psychiatry 1992;34:108-13. 18. Jain V, Singh H, Gupta SC, Kumar S. A study of hopelessness, suicidal intent and depression in cases of attempted suicide. Indian J Psychiatry 1999;41:122-30. 19. Khan FA, Anand B, Devi GM, Murthy K. Psychological autopsy of suicide: A cross sectional study. Indian J Psychiatry 2005;47:73-8. 20. Badrinarayana A. Study of suicidal risk factors in depressive illness. Indian J Psychiatry 1980;22:81-3. 21. Srivastava S, Kulsreshtha N. Expression of suicidal intent in depressives. Indian J Psychiatry 2000;42:184-7. 22. Anand R, Trivedi JK, Gupta SC. Suicidal communication in psychiatric patients. Indian J Psychiatry 1983;25:121-8. 23. Ponnudurai R, Jeyakar J, Saraswathy M. Attempted suicides in Madras. Indian J Psychiatry 1986;28:59-62. 24. Suresh Kumar PN. An analysis of suicide attempters versus completers in Kerala. Indian J Psychiatry 2004;46:144-9. 25. Devi PS, Rao VA. The premenstrual phase and suicidal attempts. Indian J Psychiatry 1972;14:375-9. 26. Palaniappan V, Ramachandran V, Somasundaram O. Suicidal ideation and biogenic amines in depression. Indian J Psychiatry 1983;25:286-92. 27. Rao VA, Parvathi Devi S. Psychobiology of suicide behavior. Indian J Psychiatry 1987;29:299-305. 28. Rao VA. Attempted suicide and suicide among students in Madurai. Indian J Psychiatry 1972;14:389-97. 29. Kumar S, Chandrasekharan R. As study of psychosocial and clinical factors associated with adolescent suicide attempts. Indian J Psychiatry 2000;42:237-42. 30. Sharma R, Vijay L, Chaturvedi S. Suicidal behavior amongst adolescent students in South Delhi. Indian J Psychiatry 2008;50:30-3. 31. Rao VA, Madhavan T. Depression and suicide behavior in the aged. Indian J Psychiatry 1983;25:251-9. 32. Rao VA, Mahendran N, Reddy GC, Prabhakar KT, Swaminathan ER, Andal BC, et al. One hundred female burns cases: A study in suicidology. Indian J Psychiatry 1989;31:43-50. 33. Jacob R, SureshKumar M, Rajkumar R, Palaniappun V. A study to assess depression, its correlates and suicidal behavior in epilepsy. Indian J Psychiatry 2002;44:161-4. 34. Latha KS, Bhat SM. Suicidal behavior among terminally ill cancer patients. Indian J Psychiatry 2005;45:79-83. 35. Satyavati K. Attempted suicide in Psychiatric patients. Indian J Psychiatry 1971;13:37-48. 36. Gupta SC, Singh H, Trivedi JK. Evaluation of suicidal risk in depressives and schizophrenics: A two year follow up study. Indian J Psychiatry 1992;34:298-310. 37. Srivastava AS, Kumar R. Suicidal ideation and attempts in patients with major depression: Socio demographic and clinical variables. Indian J Psychiatry 2005;47:225-8. 38. Goel Capt DS. Attempted suicide in the armed forces. Indian J Psychiatry 1975;17:163-73. 39. Chakraborthy PK. The significance of attempted suicide in armed forces. Indian J Psychiatry 2002;44:277-82. 40. Chavan BS, Singh GP, Kaur J. Psychological autopsy of 101 suicide cases from northwest region of India. Indian J Psychiatry 2008;50:34-8. 41. Behere PB, Behere AP. Farmers' suicide in Vidarbha region in Maharashtra State: A myth or reality? Indian J Psychiatry 2008;50:124-7. 42. Sethi BB, Gupta SC, Singh H. Psychosocial factors and personality characteristics in cases of attempted suicide Indian J Psychiatry 1978;20:25-30. 43. Sarkar P, Sattar FA, Gode N, Basanar DR. Failed suicide and deliberate self harm: A need for specific nomenclature. Indian J Psychiatry 2006;48:78-83. 44. Das PP, Grover S, Avasthi A, Chakrabarthi S, Malhotra S, Kumar S. Intentional self harm seen in psychiatric referrals in a tertiary care hospital. Indian J Psychiatry 2008;50:187-91. 45. Chowdhary AN, Banerjee S, Brahma A, Biswas MK. Pesticide poisoning in non fatal deliberate self harm: A public health issue. Indian J Psychiatry 2007;49:117-20. 46. Chowdhary AN, Brahma A, Banerjee S, Biswas MK. Pattern of domestic violence among non fatal deliberate self harm attempters: A study from primary care of West Bengal. Indian J Psychiatry 2009;51:96-100. 47. Singh AN. Discussion and evaluation of present suicide prevention activities and suggestions for future prevention activities. Indian J Psychiatry 1972;14:369-74. 48. Rao VA. Toward suicide prevention. Indian J Psychiatry 1999;41:280-8. 49. Jena S, Sidhartha T. Non-fatal suicidal behavior in adolescents. Indian J Psychiatry 2004;46:310-8. 50. Vijayakumar L. Suicide and its prevention: The urgent need in India. Indian J Psychiatry 2007;49:81-4. 51. Gupta SC, Anand R, Trivedi JK. Development of a suicidal intent questionnaire. Indian J Psychiatry 1983;25:57-62. 52. Somasundaram OS, Babu K, Geethayan A. Indian J Psychiatry 1989;31:208-12.
Lakshmi Vijayakumar Sneha, Voluntary Health Services 25/21 Ranjit Road, Kotturpuram Chennai - 600 085, India 49 A review of Indian psychiatry research and ethics
A. K. Agarwal
ABSTRACT
Ethics does not seem to be a favorite topic of Indian authors. Electronic search of the IJP web site could only identify six articles which were directly related to ethics. One article discussed the relationship of ethics religion and psychiatry. Another editorial discussed the concept of responsibility in psychiatrists. Other editorial discussed the truth about 'truth serum' in legal investigations. One article discussed the ethical aspects of published research. There were two articles that specifically discussed ethical aspects. This write-up provides some details about the ethical aspects of psychiatric practice, specific to India, and emphasizes the need to rediscover ethics in India.
Key words: Ethics, Psychiatry, India
INTRODUCTION
Ethics do not appear to be a favorite subject for Indian authors. Repeated search by electronics means at the IPS Journal website could only select six articles which are basically related to ethics in psychiatry. Many other articles were also picked up, which had hardly any connection with ethics. A brief review of these articles is essential before we can proceed further.
First article[1] selected is entitled Psychiatry, Religion and Ethics from IJP 1965. This is a very interesting article. I am fortunate to know the author who was doing course in Clinical psychology at the same time when I was studying psychiatry at the All India Institute of Mental Health, Bangalore. He was a very considerate individual very helpful and respectful for all. He could stand against authority if he felt he was on the right side. These are the qualities of an ethical person who can risk personal gains to preserve ethical values. This article is basically a reflection of his personality as well as psychiatric teaching of that time. Any mental illness was considered a consequence of psychosocial forces; the biological factors were acknowledged but not emphasized. The hypothesis put forward by Singh in this paper are as follows:
All religions are basically same and all of them emphasize on ethical behavior. Mental illnesses are caused by psychosocial stressors and if one could follow ethical path or the path of righteousness, one would not have any stress and ultimately no mental illness. The mentally ill could also gain health following a similar path. The emphasis is on ethical behavior; even today, if one follows the path of righteousness one would at least be more comfortable, if not fully healthy.
The other two articles are editorials by N. G. Desai[2] and AK Kala,[3] both very important and worth discussion in some detail.
Responsibility of psychiatrists: Need for pragmatic idealism is the title of Desai's editorial. The author quotes Chodoff to enumerate the responsibilities of psychiatrists.
The responsibilities cited are:
(i) Competence or the need to master their task; (ii) Ethical behavior or to police their ranks; (iii) Accountability or to be accountable to public; (iv) Advocacy or to be advocate for mentally ill persons.
These responsibilities are generally not emphasized. Most clinicians feel comfortable following the traditional clinical role of one-to-one relationship. The emphasis on advocacy and accountability are new concepts which are important in today's scenario. Desai emphasizes that the responsibility of being a competent psychiatrist with adequate skills seems to be undermined by varying standards of education and indifferent monitoring mechanisms. The training of psychiatrists in this country varies widely from center to center. Poor competence is also ascribed to the perception that psychiatry is not a very exact science and many people feel that exacting skill training is not required. The author further emphasizes that a psychiatrist should be well aware of the different laws that effect mentally ill persons and should respect those laws. Ethical responsibility is often ignored as the ethical guidelines are not clear and effective. The author reiterates that the psychiatrist should be able to accept and identify mental health issue within themselves and their close relatives. He feels that the public expects a mental health professional to be free of mental ill health. The editorials bring in a very relevant concept of concentric responsibilities; must do (obligatory), should do (desirable) and can do (optional) level of responsibilities. One will have to recognize that there would always be wide variations amongst mental health professional but some qualities are must and should be present in each one, while others are desirable, yet some others would add to their effectiveness.
This is an important editorial which emphasizes newer dimensions to ethical behavior like advocacy social responsibility and certain unconventional areas are included.
Kala[3] writes on "ethically compromising positions and blatant lies about truth serum'.
This editorial is very timely as Indian courts and investigating agencies are getting more and more involved with pseudoscientific methods of investigations. It is a well known fact that information obtained during chemical stimulation could be totally unreliable. The evidence thus obtained is not admissible in the court of law. Why are the investigating agencies pursuing these methods more frequently in this country? This appears to be the replacement of third degree methods used earlier. These methods are serious blow to the human rights of the accused. The mental health professionals who participate in such activities are being unethical. This also brings the profession into disrepute as the general public perceives that the psychiatrists must be using similar methods in their day to day practice. This is a timely reminder of potential ethical violation.
Chaturvedi and Somashekar[4] 2009 studied ethical aspects of published research. The authors studied the consent procedures and ethical review board's approval in published research in IJP in 2000, 2003 to 2007. Results indicated that informed consent was mentioned in 51% studies in 2000, which gradually rose to 82% by 2007. Ethics committee approval was mentioned in 2% in year 2000 and increased to 25% by 2007. Written consent procedures were used in only 40%. This is a very important area which has not aroused enough interest. There should be a very thorough screening of all research articles before publication in our journal. The purpose of such screening should not be negative to inhibit research but should be positive to promote ethical research. IJP should have an ethical consultancy group where researchers could be able to get ethical guidance at the time of planning the research.
Srinivasamurthi et al.[5] surveyed the medical profession on ethical issues. This article was not published in IJP the survey revealed that only 23% of mailed questionnaires were returned. The approximate return rate has been found to be the same in most such studies. What was more important in this survey was - majority of respondents were involved in research while very few clinicians responded. This may indicate that researchers were more concerned with ethics than the clinicians. 93% of the respondent felt that ethical training should be started at undergraduate level. This author has published two articles on ethics in psychiatry in IJP[6,7] and some at other places.[8-10]
Ethics does not appear to be a favorite topic of Indian psychiatrists and mental health workers. However, the story of our progress on ethical issues is worth recall. There has always been an ethical committee in the Indian Psychiatric Society but there were no specific input by this committee. This author was appointed the chair person of ethical committee in 1986. The author along with some other friends decided to hold a workshop on Ethics. This led to the issue of funding as this was a workshop on ethics so funding from pharmaceutical industries was avoided. It was decided to approach University Grant commission for fund allocation. When we approached the authorities of UGC they told this author point blank that they only finance project of institutions which are under Universities but the K.G's Medical College at that time was under U.P. Government so funding was not possible. As we were in the process of leaving his office, the officer concerned asked as to what was the topic of the workshop. When they were informed that it is a workshop on Ethics, he suddenly showed interest and funded the whole workshop including the printing of the proceedings. This incident is given in some detail to emphasize that ethics still produces positive vibes in many and ethical behavior is still in demand. The proceedings of this workshop were published in1989.[9] Deliberation led to the formulation of ethical guidelines of IPS which were adopted by the society in Cuttack conference. These guide lines were never discussed again and there had not been any discussion on ethics in any of the forums of the Indian Psychiatric Society. There had been one or two symposiums on ethics of drug trials. Medical council of India[11] has published ethical rules in 2002.These are guidelines but they have the authority of law. One has to remember that every doctor in India has to follow them; there could be additional specialty specific guide lines. American psychiatric association also first details ethical guidelines of American medical association than elaborates on guidelines specific to psychiatry. There are some other publications related to this topic. The following is based on these publications as well as on the ethical guidelines of American Psychiatric association. ETHICAL ISSUES SPECIFIC TO PSYCHIATRY
Diagnosis
The diagnostic method used in psychiatry is behavioral observations and there are hardly any investigations that can clinch the diagnosis. Symptoms used in diagnosis can be seen normally; there is only a difference in frequency or severity. Deviance from social norms was at times considered a symptom of psychiatric illness. Though the reality of mental illness is now accepted by all there are still gray areas which do not fulfill the robust criteria of diagnosis e.g. personality disorders or grief. One will have to be very careful in diagnosing a person mentally ill and continuous revision and updating of diagnostic criteria is the only way by which we can avoid the criticism of being a pseudoscience. It is the duty of the mental health professional to note ones observations correctly, get inputs from sources like family, employer, and primary physician and then draw conclusion. A scientific diagnosis is essential to ethical practice. Psychiatry has been misused in many countries where the non conformists were sent to mental hospitals to crush dissent.
Psychiatrist patient relationship
All medical treatment is based on physician-patient relationship. This relationship is generally between two equally autonomous people who can evaluate the advantages/disadvantages of the relationship and may decide to continue or break the relationship when they want. However, the situation could be quite different in the mentally ill. The patient, because of his illness which affects his thinking, emotions and cognitive functions may be less empowered than the psychiatrist and may not be able to take independent decision. This inequality puts greater burden on the psychiatrist and he must ensure that the patients well being, should be foremost concern and therapist's personal benefits should be kept in the background. Patient should not be exploited physically, sexually, emotionally or financially.
Patient-doctor relationship in the field of mental health is prolonged and as intimate personal details are being disclosed, there is a likelihood of development of strong relationship (transference).These relationships may lead to inappropriate behavior of strong love or hatred and the therapist needs to be vigilant and not let these vitiate the therapeutic relationship.
Involuntary treatment
Most psychiatric patients believe they are not ill and refuse treatment. Hence they are treated against their wishes. Laws of each country recognize this problem and therefore they have provided legal safeguards for there treatment. Mental Health Act 1987 of India[12] provides for involuntary hospitalization with the consent of caring relative or through legal procedure. Unfortunately or fortunately, majority of the mentally ill are treated either as out-patients or in psychiatric units of general hospitals. These patients are either treated with relative's consent or they are made to sign a consent which they do not understand. Szasz calls this practice of voluntary admission an unacknowledged example of medical fraud.[7] The current situation in India can lead to unethical practice where a person's autonomy is restricted without legal safeguards.
Madrid declaration states that "Involuntary intervention is a great infringement of the human rights and the fundamental freedom of a patient. Therefore, specific and carefully defined criteria and safeguards are needed for such intervention. Hospitalization or treatment against the will of the patient should not be carried out, unless the patient suffers from severe mental illness. Involuntary intervention must be carried out in accordance with least restrictive principle."
Hawaii declaration of WPA states, "No procedure must be performed or treatment given against or independent of patient's will, unless the patient lacks capacity to express his or her own wishes, or owing to psychiatric illness can not see what is in his best interest or, for the same reason is a severe threat to others. In these cases, compulsory treatment may or should be given, provided it is done in the patient's best interest and over a reasonable period of time, a retroactive informed consent can be presumed and whenever possible, consent has been obtained from someone close to the patient. As soon as the above conditions for compulsory treatment or detention no longer apply, the patient must be released, unless he or she voluntarily consents to further treatment. Whenever there is compulsory treatment, there must be an independent and neutral body of appeal for regular enquiry into these cases. Every patient must be informed of its existence and permitted to appeal to it, personally or through a representative without interference by hospital staff or by anyone else".
The major situations where one could recommend involuntary hospitalization, according to Mental Health Act 1987, are as follows:
1. Patient is dangerous to self/others
2. There is a possibility of improvement by hospitalization
3. The patient is incompetent
The psychiatrist and the mental health team should closely monitor the patient for competence to make informed decisions and as soon as the patient is able to make such decisions he should be given the liberty of choosing the treatment option. This aspect is not really practiced in this country. Large numbers of mentally ill patients who have improved are still in the hospitals as there family members are not ready to accept them or they have no place to go or the family wants them to stay in hospital to avoid the inconvenience of keeping them at home. This is a serious lapse of patient's human rights and the profession need to look into it.
Most of the patients in this country are being treated as outpatients. The uncooperative patient is given medicine surreptitiously or by injections against their will with the consent of family members. This is being done keeping in mind the principle of beneficence and is ethically acceptable. The problem with this practice is that it can be misused by some. Secondly, this has resulted in revolving door phenomenon. The relatives give the medicine to the patient only till such times the acute symptoms subside and thereafter stop it. Some times the patient refuses to take it but often there is a mutual hidden agreement between the patient and the relatives that the medicines are no longer required. This leads to frequent relapses. There is an urgent need to develop patient and family information material, which could help them decide when to continue or stop treatment.
Confidentiality
It refers to therapists responsibility of not disclosing information learned during treatment to any one without the patient's permission. It is the patient's privilege and should be respected except in certain predefined situations. It is important to differentiate between the patient's privilege of respect to his confidentiality and the legal requirements of withholding medical information. These two are not the same. It is prudent to inform the patient that the information provided by him will be kept confidential except in the exceptions as enumerated later. Earlier the families were not provided the confidential information but now the families are considered an important part of therapeutic activity and the patient's need to be encouraged to share required information with the family. Therapists who do not take care of the confidence of people by their acts of omission or commission would be considered unethical. Doctors who expose patient's private part in front of others are guilty of breach of ethics. Psychiatrists who ask confidential matter from the patients in front of relatives or other strangers are guilty of the same. The case records of patients should not lie unguarded where they could be accessed by any one. It would show that the psychiatrist is not taking enough precautions in protecting the patient's confidences. If case records are being maintained in the electronic form one need to be more vigilant so that these could not be accessed by unauthorized persons. It is always prudent not to mention seriously incriminating information in the case sheet where it could be accessed by others. Gossiping about patients or publishing case records without hiding the identity of the patient or without his permission would amount to breach of confidence.
With whom one can share this information without the permission of the patient.
The confidential information could be shared with the treating team which may include nurse, psychologist, social workers and other personnel actively involved in treatment. All of them should be sworn to keep the confidentiality and in case of any breach by anyone of them, the responsibility would of the psychiatrist. Very often the family members, the employer and the authorities wish to know about the patient. The psychiatrist should provide confidential information only after obtaining explicit permission from the patient.
Major exceptions to confidentiality
1. Patient consents to release information to family members, employer, and insurance company or to anybody else.
2. Tarasoff duty: When patient's acts are likely to harm others then it is the doctor's responsibility to protect others from harm. If a patient informs the doctor that he is going to kill some one than it is doctors ethical responsibility to take appropriate action so that the intended victim could be protected. We often come across instances when a mentally impaired person can harm others by his negligent behavior e.g. Persons engaged in running public transport like buses trains etc, officers in police army or doctors. It is the responsibility of the treating doctor to take appropriate action and avoid the possibility of public harm.
3. Emergencies: When patients life is at stake the confidences can breached so that he gets efficient care.
4. Mandatory reporting: Whenever any kind of human right violation is observed like child abuse, female abuse than it has to be reported to appropriate authorities. Persons who are HIV positive and plan to marry should be encouraged to inform the spouse. If they do not agree to do so then the psychiatrist can inform the spouse to protect him or her.
5. Court orders: If a court of law asks for some confidential information than psychiatrist should seek permission from the patient. If the patient refuses permission, the psychiatrist should inform the court of the same. If the court even then directs that he should reveal the confidences than he could do so. 6. Patient initiates litigation against the psychiatrist: The psychiatrist can reveal such confidences that are directly relevant to the case.
Principles to follow when breaching confidence is necessary
1. Inform the patient wherever possible. Seek his consent 2. Disclose only the relevant information 3. Document rationale for action
Confidentiality endures after death, and one should not disclose information unless next of kin provide consent.
Honesty and trust worthiness
Honesty and trust are the basis of doctor patient relationship. Honesty entails positive duty to tell the truth as well as the negative duty not to lie or intentionally mislead some one. Psychiatrist often learns many a sensitive information about the patient and some times try to hide the information to protect the patient. In general, omission (intentional failure to disclose) and evasion (avoidance of telling the truth) will undermine a constructive relationship and is not appropriate. Large number of patients and their relatives repetitively request the psychiatrist to provide a certificate of illness that may not affect their jobs or marriages. Acceding to such requests would undermine the principles of honesty and trustworthiness and would bring down the prestige of the profession.
Non participation in fraud
Fraud is an action that is intended to deceive and ordinarily arises in the context of behavior that seeks to secure unfair or unlawful gains. This is an extension of the principle of honesty and trustworthiness. One may be tempted to help a patient by providing false information regarding his illness or treatment but in the long run it is going to undermine the trust of the patient as well as others especially third party providers. The specific examples are writing the prescription in some other name where patient could get free medicines, or changing the diagnosis in the certificate or not informing the employer of the potential hazards this illness may entail on the work of the patient. The psychiatrist should avoid all kind of wrong doings to uphold the dignity of the profession. Such conduct will be beneficial to the patient in long term.
Informed consent The concept of informed consent has gain importance since 1950. The concept is still evolving. This concept is centered on three aspects;
Information - What is to be informed and how.
Is the patient competent to understand the information and can make rational decisions.
Can the patient take autonomous decisions without being influenced by the disease process cultural factors, or other extraneous factors?
Information - The patient should be informed about the nature of the illness. What is the diagnosis and what is the likely course if untreated and what is likely to happen with different treatments available. What treatment the doctor is recommending and why. What are the likely side effects of the treatment? What is the duration of the treatment? What is the cost of the treatment? What is the most cost effective treatment? Whether this treatment has strong evidence base.
Second question to be considered is how much is to be informed. This varies from State to State in USA. Some state requires that what is generally informed by doctors should be informed. While others would require reasonable information which an individual would require for mature decision making. The second option appears more reasonable. This issue has not been discussed in this country. If one is informing about the side-effects of a treatment should he inform only the common and less harmful side effects or he should inform rare but fatal side effects. The later could scare the patient.
The third question is how to inform. Should the information be oral or written? In research written information is mandatory. Oral information can be distorted and the patients and relatives may be induced to accept what the doctor's desire. Ideal should be written information which could be further discussed. The next question is that who should obtain consent, the treating clinician or some other person who may not have any stakes in treatment.
Competence - Can the patient or the relative comprehend what is being informed. Can he process this material to reach a sound decision? Ordinarily, every adult is considered competent and should be able to make a choice. The psychiatrist should assess the ability of the patient to comprehend information to process it rationally, and to reach sound decisions. Sometimes patients who have cognitive deficits or psychotic symptoms can give a valid consent, if information is presented in small parts. In reality not even many mentally healthy person can understand the medical jargon and not many can decide whether to consent for ECT or drugs. Such decision making is mostly influenced by hearsay, prejudices and stigma. Ideally, a medical decision could only be made by a medical man. The medical men should discuss the decision with the patient and family members and they should be informed of all the advantages and the disadvantages of the proposed course of action. The patient could also be encouraged to seek a second opinion from a competent psychiatrist of their choice.
Autonomy - Can the patient make an autonomous decision. Often the illness can affect the individual in such a way that he may be incapable to make an autonomous decision. Depressed patient may be so fed up with life that he may consent to any treatment without fair consideration. Persons suffering from alexithymia will not be able to make a decision. The situation in India is more complex due to deficient manpower. There are very few mental health facilities and thus the patient has to accept what is being offered as there are no alternatives. Poverty could be another factor.
The concept of informed consent is surrounded by controversies. Some feel it is a consequence of defensive medical practice in the US, where litigations are frequent. When consent has been obtained than the legal liability of the clinician is very much diminished. Large number of psychiatric patient does not consider them to be ill and thus refuse consent. This will results in delayed or no treatment. Autonomy of the patient can also be restricted by biases and prejudices. Many patients believe in some the following. • Mental illnesses are a result of ones own faults and they should be controlled by them personally. • Mental illnesses are caused by supernatural powers hence the religious treatment is appropriate. • Mental illnesses are caused by circumstances and unless they are changed no treatment can be helpful. • Psychiatrist prescribes sleeping pills and that leads to addiction and not treatment. • Psychiatric treatments like ECT may cause more harm than the illness. • If one takes psychiatric treatment once then he has to take it for the life time.
These and similar biases and prejudices influence the patients decision making process. Therefore it is essential that the clinician educate and inform the patients about the reality of these myths.
The consent should not be blanket consent as is often practiced in this country. There is a consent form on the first page of the case record and each patient or the relative is asked to sign this blanket consent. Consent should be obtained for each procedure separately and the patient can give a limited consent or may revise it after some time. The procedure of consent has not been sufficiently discussed in this country and it is high time that we evolve consent procedures that are relevant to our needs.
The Supreme Court of India[13] in its judgment on January 16, 2008, held that a doctor has to seek and secure the consent of the patient before commencing a 'treatment'. Giving the judgment the three judge bench said that "the consent so obtained should be real and valid; the patient should have the capacity and competence to consent; his consent should be voluntary; and his consent should be on the basis of adequate information concerning the nature of the treatment procedure, so that he knows what he is consenting to." This judgment comprehensively sums up the consent process and the Supreme Court decisions have the power of the law.
Exceptions to informed consent 1. Emergencies 2. Therapeutic privilege-In situations where giving of all the information necessary to make a decision could harm the patient the therapist can withhold information. This should be a rare exception. Under such circumstances the rationale of withholding information should be recorded. 3. Incompetence due to mental condition or in cases of minors 4. Waiver-when the patient has explicitly stated that he accepts all the decisions of the treating team
Professional competence
The professional competence of the doctor is the key to ethical practice. A person who is not sufficiently trained or has not kept himself up to date in knowledge can not provide competent care. The psychiatrist should continue to update his knowledge. Medical Council guidelines recommend that the professional should join professional societies where he could update knowledge. It is time that we should evolve a more concrete method of lifelong learning and its evaluation.
Every clinician should be aware of his expertise and should not treat conditions falling outside his expertise. A cardiologist treating a psychiatric patient or vice versa are clear examples of unethical behavior. One can treat beyond his expertise only in emergencies or when specifically trained professional is not available. Physicians who are incompetent due to age or illness should stop clinical work. It is the duty of every physician to report such persons to appropriate authority so that they do not harm the unsuspecting patient.
Physicians involved in unethical behavior should also be identified and reported so that the profession could not be painted black due to nefarious activities of few. Unfortunately we Indians have a great capacity to tolerate deviance due to which black sheep of the profession thrive.
Relationship with colleagues
The psychiatrist should treat their colleagues with respect. The opinion of a colleague should not be criticized in front of the patient and his relatives. If the colleague is involved in unethical behavior than the same could be reported to appropriate authorities.
Referral
If one finds that he does not have enough expertise to treat a particular patient then he could be referred to a person who has the requisite skills. If a patient has not responded reasonably to treatment, the patient should be referred to a colleague for second opinion or further treatment. If an unconventional treatment is proposed than a second opinion should be sought. If the patient is not satisfied with the treatment than he should be encouraged to seek a second opinion.Charging of fees from colleagues and their families
The ancient medical ethics prohibited the charging of consultation fee from colleagues, teachers and their families. This issue needs to be debated keeping the current realities in mind.
Boundary violations
A boundary may be defined as the "edge" of appropriate professional behavior, transgression of which involves breaching the clinical role. Boundary issues involve the therapist's role and his relationship with the patient and his family. Issues may include the following
• Time and place of consultations, contacts on phone, in social meetings etc • Accepting or giving of gifts, money • Making inappropriate arrangements of payment of dues in cash, kind or barter system • Types of clothes the doctor wears or the language he uses could involve boundary violations • Talking about self in therapeutic situation • Physical contact including sex but not limited to it
The therapeutic relationship between a doctor and the patient is established solely with the purpose of therapy and whenever this relationship deviates from its basic goal of treatment it is called boundary violation and becomes non therapeutic. In psychiatry, as the therapeutic relationship is prolonged and more personal as many confidential matters are discussed, there is likelihood of developing strong emotional bonds. This may lead to non therapeutic activity.
1. Sexual activity with a patient, ex-patient or with the patient's family member is unethical.
2. Business relationship with a current patient is unethical except when one is living in a small community where such relationship can not be avoided.
3. Ideological: Any clinical decision should be based on what is best for the patient; the psychiatrist's ideology should play as little a part as possible in such decisions. The psychiatrist may be against inter-religion marriages but if the patient wants it than his wishes should be respected.
4. Social: Whenever the psychiatrist and the patient start becoming friendly then the therapeutic relationship is compromised. The objectivity is compromised and factors outside the therapeutic relationship may become destructive to the therapeutic process. Psychiatrist should avoid non therapeutic contact with the patient. Similarly, one should not treat one's friends. The place of consultation should be clinic and the time should also be during the consultation hours. Any deviations would distort the therapeutic relationship.
5. Financial: If the patient is being treated in a state hospital where no fee is charged then the doctor should not accept any gift in form of cash or goods. Small gifts on special occasions could be justified. Very often, influential people like politicians and government officials may offer special privileges for the doctor or his department but all such concessions or allurements are also unethical. If the psychiatrist charges fees he should keep charges that are reasonable for that area. Still there could be patients who would not be able to pay. There should be a transparent policy of fee reduction. It should not be done differently for different people because that may again distort relationships.
6. Dress and language: Doctor should be dressed formally. Dresses that are flashy or reveal body part in a provocative manner should be avoided. The language used should be formal and abusive or double meaning words should be avoided.
The doctor is responsible for preserving the boundary and he should ensure that boundary violations do not occur. If even a minor violation occurs it is better to transfer the patient to a colleague. The boundary violation typically starts small and become incrementally problematic and the dyad starts sliding down the slope. This is known as Slippery Slope Concept.
Double agentry
This type of conflict arises when the psychiatrist has responsibility to another agency which might be his employer in addition to his responsibility to the patient. A psychiatrist in the armed forces is duty bound to inform his superiors if any one of his patient develops a psychiatric illness which might be a security risk. Similarly, psychiatrists employed in other industrial organizations could be duty bound to provide certain information to there employers. In western countries where health care is provided by third parties treating doctors are expected to provide information to them.
The psychiatrist should inform the patients at the start of the treatment about his obligations to provide information to specific agencies and an informed Consent should be obtained.
Conflict of interest
Conflict of interest is "a set of conditions in which professional judgment concerning a primary interest (such as patients' welfare or validity of research) tends to be unduly influenced by a secondary interest (such as financial gain)".The relationship between physician and pharmaceutical industry, research on patients and physicians relationship with health providers are examples of such conflict of interest.
Relationship with pharmaceutical industry is the center of focus these days. It is said that the pharmaceutical lobby influence medical publishing, as well as doctors prescribing habits. There is good evidence that pharmaceutical industry is a main sponsor of research. It is believed that nearly 50% of articles dealing with therapeutics appearing in Lancet and BMJ are ghost written.[14] The recent example of inappropriate promotion of drugs like Alteplase and Xigris are testimony of pharmaceutical industries influence on research and publication.[15] Clinician has to be very vigilant that his decision may not be influenced by such misreporting. There is some evidence that even meta- analysis could also be tampered with by interested parties. It is therefore important that the profession remains vigilant It is now accepted by almost all ethical organizations including MCI that only small gifts could be accepted by the doctors from the pharmaceutical industry. Pharmaceutical sponsored Continuing Medical Education (CME) would generally serve the industries interests. Most of our conferences and other research needs are being sponsored by the industry - Is it a healthy sign. This may result in inappro priate prescription of drugs which is totally unethical.
The health service providers also influence clinical decisions. Health authorities in our country insist that the doctors should prescribe only those medicines that are available in the hospital. This interferes with one's clinical decision making. Similarly in the west where insurance companies fund health care they decide when the patient should be admitted or when he should have psychotherapy thus effecting clinical decision making.
Ethical issues in day- to-day clinical work
Ethical behavior should be part and parcel of day to day clinical activity. How much information has to be obtained for effective diagnosis and clinical care is an ethical issue which is often ignored. If a patient has a small injury in his toe we need not disrobe him completely. Similarly psychiatric history taking and examination should be need based and unnecessary details of intensely personal matters like sex or other emotional relationship should only be obtained when needed.
Patient should be informed about diagnosis, treatment and likely prognosis.
How much is to be informed and to whom should follow well established practices.
Patient and families will ask many questions and these should be answered. The answer should not be given without proper thought and should be based on available evidence. Usually the relatives of seriously sick patients may ask questions regarding marriage, likelihood of inheriting the disease or the effect of disease on work or family life. All these questions have to be answered after weighing available evidence. If one is not sure of the answer then one can even tell the family members that he will need to find out from some one else. Often the doctors give false assurances or try to hide serious long term consequences to reduce the pain and suffering of the patients, but such acts often misfire. The father of a girl with schizophrenia told this author that if the earlier psychiatrist would have told him that this illness is likely to relapse he would not have married his daughter. A well intended act has led to an emotional disaster. The doctors should be very careful in use of words and should always stick to the truth; well intentioned half lies or evasions are not ethical.
Ethical consideration should influence even minor clinical decisions. Writing costly medicines when same medicine is available at a cheaper cost is an ethical transgression. Unnecessary investigations, medications or referrals are unethical.
Ethics in research
The whole world has become very vigilant on the question of research involving human subjects. There is large number of international and national guidelines for research involving human subjects. The Indian Council of Medical Research has published such guideline for uses in India.[16] Some of the basic issues to be addressed in research are following:
The research project should be carefully planned so that it can answer the research questions that it wanted to answer. Poorly conceptualized research project is highly unethical as it wastes national resources and put unnecessary strain on the subjects.
The welfare of the patient should be prime concern. Research that could produce potential harm should be carefully monitored. The use of very complicated informed consent is often counter productive and the researchers obtain consent for what they want. The offer of money for travel etc and use of new imported medicines are the inducement used to obtain consent from poor unsuspecting patients.
Use of placebo in patients where standard treatments are available poses serious ethical dilemma. The institutional review boards (IRB) are mandatory for ethical clearance of research projects. There are no restrictions on who can select the members of IRB. Often the institutional heads appoint an IRB that is convenient to them. Most IRB do not pay enough emphasis on the follow up of research project.
CONCLUSIONS
Ethical practice is fundamental to effective and rational treatment.
Ethical aspects of psychiatric practice have not been properly discussed and there are no effective guidelines to guide the psychiatrists in there clinical work.
Ethics are evolving and one should be ready to change with times.
There are no irrefutable principles and the clinician has to learn to find the most suitable and best fit for each clinical situation.
There is a need to evolve ethical guideline applicable to psychiatry for this country.
Till such time such guidelines are not available, the basic rule that should guide every clinician's behavior is that one should not do to others that one would not like to be done to him.
ACKNOWLEDGEMENTS
The author gratefully acknowledges the help obtained from "Proposed changes to APA Guidelines: Principles of ethics and professionalism in psychiatry". The author also acknowledges the help obtained from an unpublished draft entitled 'Ethical issues in Psychiatry' by Sivakumar T.
REFERENCES
1. Singh H. Psychiatry, Ethics and Religion. Ind J Psychiatry 1965;7:278-86. 2. Desai NG. Responsibilities of psychiatrists: Need for pragmatic Idealism. Ind J Psychiatry 2006;48:211-4. 3. Kala AK. Of ethically compromising positions and blatant lies about truth serum. Ind J Psychiatry 2007;49:6-9. 4. Chaturvedi SK, Somashekar BS. Reporting ethical aspects in published research articles in the Indian Journal of Psychiatry. Ind J Psychiatry 2009;51:34-7. 5. Srinivasamurthy R, Raghavan KS, Chatterji S, Verghese M. Ethical issues in Medicine-an opinion survey. In: Bhatala PC, editor. Proceedings of International Conference on Health Policy, Ethics and Human Values. New Delhi: IMA House; 1986. 6. Agarwal AK. Ethics in psychiatry. Ind J Psychiatry 1994;36:5-11. 7. Agarwal AK. Ethical issues in the practice of psychiatry. Ind J Psychiatry 2001;43:16-21. 8. Agarwal AK. Ethical issues in the treatment of mentally ill. In: Bhatala PC, editor. Proceedings of International Conference on Health Policy, Ethics and Human Values. New Delhi: IMA House; 1986. 9. Agarwal AK. Proceedings of workshop on ethics in psychiatry. Lucknow: Dept Psychiatry K.G's.Medical College; 1989. 10. Agarwal AK, Gupta SC. Ethics in Psychiatry. In: Vyas JN, Ahuja N, editors. Text Book of Post Graduate Psychiatry. New Delhi: Jaypee; 1999. 11. Medical Council of India. The Indian Council (Professional Conduct and Ethics) Regulations; 2002. 12. Mental Health Act. Government of India; 1987. 13. Available from: http://www.hindu.com/2008/01/17stories/ 2008011753701300.htm. 14. Healy DT. Transparency and trust: Figures for ghost written articles was misquoted. BMJ 2004;329:1345. 15. Singh AR, Singh SA. Guidelines, Editors, Pharma and the Biological Paradigm Shift. In: Singh AR, Singh SA, editors. The Academia-Industry Symposium MSM 2007: Medical Practice and the Pharmaceutical Industry, and ever the duo shall meet. MSM, vol. 5. 2007. p. 27-30. 16. Ethical Guidelines for Biomedical Research on Human Subjects. Indian Council of Medical Research New Delhi: 2000. SUGGESTED FURTHER READING 1. Duckworth K, Blumberg L, Bienefield D, Kahn M, Kapp M. Law, Ethics, and Psychiatry. In: Allan T, Kay J, Lieberman JA, editors. Psychiatry. 2nd ed. Wiley; 2003. 2. Ethics in Psychiatry. Psychiatry clinics of North America 25, 2002 issue. 3. Fulford KW, Bloch S. Psychiatric ethics: Codes, concepts, and clinical practice skills. In: Gelder MG, Juan Lopez-Ibor Jr, Andreason NC, editors. New Oxford Textbook of Psychiatry. 1st ed. Oxford University Press; 2000. 4. Lubit RH, Ladds B, Eth S. Ethics in Psychiatry. In: Sadock BJ, Sadock VA, editors. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams and Wilkins; 2005.
This is a condensed version of a chapter written for a book on Mental Health to be published by DGHS Government of India.
A. K. Agarwal Retd. Professor Department of Psychiatry, K.G's Medical College, Lucknow, India 50 Change the title as: Forensic psychiatry revisited: Review of Indian journal of psychiatry articles since 60 years
S. Nambi
ABSTRACT
Articles related to Forensic Psychiatry published in the Indian Journal of Psychiatry and Neurology and Indian Journal of Psychiatry during the last 60 years revisited. During these years, around 50 articles have been published in this subject. Psycho-criminology is the theme dealt with in most of the articles. Highlights of some of the important articles are mentioned.
Key words: Forensic psychiatry, mental health legislation, psycho- criminology
INTRODUCTION
It is a great opportunity to review the articles related to forensic psychiatry, which were published in the Indian Journal of Psychiatry (IJP) during last 60 years.
In the modern days, almost every aspect of life is regulated or affected in some way by law. All civilizations in the world have enacted laws to regulate human behavior, so that even the weakest can live freely and enjoy all the human rights. Legislations form the important component in the implementation of mental healthcare. There is a dynamic relationship between the concept of mental illness, the treatment of the mentally ill and the law.
"Forensic Psychiatry is a poorly defined specialty with little organized training in most countries." (WHO working group) Working knowledge of the law that regulates the practice of psychiatry assists clinicians in providing good care to patients. Psychiatrists cannot be expected to be as knowledgeable of the law as lawyers, but they do need to understand how the law and psychiatry interact in various common clinical situations.
In reviewing the forensic-related articles published in the Indian Journal of Psychiatry (IJP) during last 50 years, it is noted that there are only around 50 articles cited. If we were to classify these articles, they would fall under the following three heading: 1. Psycho-criminology related articles - there are around 38 articles. 2. Mental health legislation articles - numbered around 5 and 3. The others are around eight
There is one letter to the Editor and Book Review for the book titled "Psychiatry and law" by J.C.Marfatia in 1972. These are other interesting findings in analyzing these articles. There are totally eight articles related to forensic psychiatry during the past 50 years of IJP, which include one invited editorial. They are: 1. Indian Journal of neurology and psychiatry of October 1949, the editorial titled "Indian Lunacy act" (author unknown) 2. B.B. Sethi. "Cult Of violence" in 1984 3. B.B. Sethi. "Need for Growth of Forensic Psychiatry" in 1984 4. S.M. Channabasavanna. "Dialogue with Judiciary" in 1985 5. A.K. Aggarwal. "Mental Health and the Law" in 1992 6. T.S.S. Rao. "Psychiatrist and the Science of Criminality" in 2007 7. T.S.S. Rao. "Criminal Behavior - A dispassionate look at parented disciplining practices" in 2007 8. A.K. Kala. Invited Editorial titled "of Ethical Compromising Positions and Blatant Lies about Truth Serum" in 2007
These are two articles of Murthy Rao oration delivered by R.C. Kapoor in 1994 tilted "Violence in India - A Psychological Perspective" and L.P.Shah in 1999 titled "Forensic Psychiatry in India-Current Status and Future Development"
It is heartening to note that the two presidential addresses are in Forensic Psychiatry, the first one by O. Somasundaram in 1987 on "The Indian lunacy act - 1912" the historic background; and the second one by S.Nambi on "Marriage, Mental Health and Indian Legislation" in 2005. It is to be noted here that the Presidential Address by J.K.Trivedi in 2004 on "Terrorism and mental health" is also to be taken into account. Incidentally, both these presidents are from Chennai, South India. At this juncture, it is to be noted that majority of the forensic psychiatry articles in the last 50 years, around 20 are from the South and many of them are from Chennai center. The central zone (Lucknow) followed by north and west zone represent the second, third and fourth in the descending order in this category. Even though the East zone members have done some pioneering work in forensic psychiatry, only a few articles have been published. It is to be noted here that there are three forensic psychiatry articles authored by foreign authors and one by military (Navy) psychiatrists. Apart from the two presidential addresses, specifically in forensic psychiatry, Vidysagar's Presidential Address in 1973 and V.S.P. Basyam's Presidential Address in 1997 have some important points mentioned about Forensic Psychiatry and Mental Health Legislation.
When we review the Forensic Psychiatry articles in the IJP articles, we cannot miss one name ie; O. Somasundaram of Chennai. Among all the articles on Forensic Psychiatry published by the IJP, the contribution by O. Somasundaram is nearly one-fourth. His articles include following: 1. Guilty but insane-some aspects of Psychiatric Crime - 1960 2. Insanity versus Criminal Responsibility -1964 3. Psychiatrically Ill Under Trail Patients - 1969 4. Men who Kill their Wives - 1970 5. Crimes of Persons with Epilepsy - 1972 6. The Mothers who Kills their Children - 1973 7. Crimes of Persons with Schizophrenia - 1974 8. Crimes of Persons with Affective Disorder - 1977 9. Murder in Tamil Nadu - a Study of Murder Trial - 1980 10. A Study of Delinquent Boys - 1980 11. The Indian lunacy act - 1912 the historic background: The Presidential Address - 1987 12. The Psychiatry of Assailants of Tamil Nadu Chief Ministers - 1992
In his Presidential Address on "The Indian lunacy Act-1912 the historic background," he traced the evaluation of legislation of various countries with a special mention on British Legislations. At that time, he mentioned that the Indian Lunacy act was out modeled and should be replaced and that there is a need to change the Act for a more comprehensive Mental Health Act. Nambi, in his Presidential Address in 2005, mentioned the changing concepts of marriages in India with special emphasis on the increased rate of divorce. He narrated the relation between marriage and various mental health problems. The important aspect of his article in "Marriage, Mental Health and Indian Legislation" is the various legal procedures outlined by different personal laws in this country. He also mentioned as to how the unsoundness of mind affects the capacity to marry and form a ground for divorce, based on these personal laws prevailing in India.
It is worthy to mention here, two important articles: One by B.B. Sethi in his editorial in 1984 and the other by L.P. Shah in his DLN Murti Oration in 1999. To quote B.B.Sethi "Majority of patients who require the expertise of a Psychiatrist are those who may harm themselves or the society, are not able to look after the welfare of their family or property and may turn out to be dangerous if allowed to act out of their thinking. Their management quite often requires taking away their basic civil rights, involving freedom, activities and residence. According to existing laws in force, such restraints can be imposed only through a due process and thus it is imperative that the psychiatrists be familiar with these". To quote L.P. Shah, "a large number of mental health, legal and law enforcement professionals are ignorant of mental health related laws. This is indeed a very shocking state of affairs and there is an urgent need to correct the situations" to quote L.P. Shah again, "there is hardly any literature in India, clarifying the topics like negligence, informed consent, confidentiality, certification, seclusion, suicide, homicide and the complication of various therapies." He also recommended that the level of teaching and research in the area of Forensic Psychiatry be upgraded and the in-service programs for the medical and psychiatric personnel, the judiciary and the law enforcement bodies as well as social welfare organization to protect the Human Rights of the Mentally ill be enhanced.
CONCLUSION
Forensic Psychiatry is a clinical subspecialty of psychiatry. The subject is concerned with an area where psychiatry and law meet. It overlaps interfaces and interacts with psychiatry and law in all aspects. Law is the sanctioning discipline in psychiatry is the therapeutic discipline. Due to various reasons, Forensic Psychiatry is reared as Cinderella in our country, which is much neglected, ignored, misinterpreted and misunderstood. It is very essential that more and more articles based on the modern concept of Forensic Psychiatry and the practical implementation and difficulties of various laws relating to mental health should be published periodically in the IJP. Of course, there are a few psychiatrists in the country with interest in Forensic Psychiatry, who carry out some work in this area, but the main problem of our psychiatrists is that they do not document or publish it. For example, the authors of this article have presented and published more than 50 articles in various souvenirs, regional journals and in the national and international conferences and CMES. But, hardly only one or two of these have been published. We have to understand that the scientific work which is carried out should be documented or published; if not documented it means it is not done.
REFERENCES
1. IJP, Electronic-Indian Journal of Psychiatry. 2009;???vol: Page no missing 2. Nambi S. Legal aspects of psychiatry-Indian Perspective. Manashanti Publications; 2008. 3. Nambi S. Marriage, mental health and the Indian legislation. Indian J Psychiatry 2005;47:3- 14. 4. Robert I, Simon, Daniel W, Shuman. Clinical Manual of Psychiatry and Law. 2007??vol: Page no missing 5. Sethi BB. Need for Growth of Forensic Psychiatry. Indian J Psychiatry 1984;26:1-2. 6. Shah LP. Forensic psychiatry in india current status and future developments. Indian J Psychiatry 1999;41:179-85. 7. Somasundaram O. The Indian Lunacy Act, 1912 The Historic Background. Indian J Psychiatry 1985;29:3-14.
S. Nambi Department of Psychiatry Sree Balaji Medical College and Hospital Chennai - 600 044, India 51 A review on Indian culture and psychiatry
Shiv Gautam, Nikhil Jain
ABSTRACT
'Culture' is an abstraction, reflecting the total way of life of a society. Culture uniquely influences mental health of people living in a given society. Similarity in thinking and understanding of mental health across the ancient cultures has been observed. Studies which relate to the demographic factors, cultural factors influencing presentation of illness, diagnosis of the illness- culture bound syndromes and influence of the cultural factors and the belief system on psychopathology, stigma and discrimination towards the patient have been reviewed. An attempt has been made to critically look at the research on culture and psychiatry in different areas. There is a need for culturally oriented modules of non-pharmacological management.
Key words: Culture & Psychiatry, culture bound syndromes, belief system
INTRODUCTION
'Culture' is an abstraction, reflecting the total way of life of a society. It is a precipitate of the group's history and an expression of its adaptation to the physical environment. It refers to the shared patterns of beliefs, feeling and behavior and the basic values and concepts that members of the group carry in their minds as guides for the conduct. Besides social relationships, economics, religion, philosophy, mythology, scriptures, technology and other aspects of living contribute to the culture. Culture is constantly in the process of change and it is transmitted from one generation to the next. All societies have it though their styles vary from one group to another.[1]
The term "culture", which is a keystone in psychiatry, is plagued by confusion because of a lack of concise, universally acceptable definition. In fact at least one hundred and sixty different definitions exist. Culture is thus best conceptualized as a totality, composed of a complex system of symbols possessing subjective dimensions such as values, feelings, and ideals and objective dimensions including beliefs, traditions, and behavioral prescriptions, articulated into laws and rituals. This unique capacity of culture to bind the objective world of perceived reality to the subjective world of the personal and intimate, lends it, its powerful role as expressor, mediator, and moderator of psychological processes and, ultimately, emotional disorders.[2]
Culture uniquely influences mental health of people living in a given society. Mental health problems, from presentation of illness to course and outcome, at every stage are influenced by cultural issues. Large numbers of patients get referred to the physician or psychiatrist of their cultural milieu as he/she can understand the patient and his psyche due to the understanding of cultural factors which influence the disease and healing process.
No culture confers absolute immunity against psychological vicissitudes. The forms of psychiatric disorders are identical in all cultures though the content of symptoms differ. For example, an Indian peasant when deluded complains of being possessed by a demon, while his western counterpart believes that his mind is being manipulated by electronics. It was believed a few decades ago, that people from oriental cultures experienced little or no stress. Mental illness and stress-related disorders like heart disease, high blood pressure, diabetes,cancer and suicide behavior were considered to be less frequent amongst them. This really is not so. Transcultural studies indicate that populations, exposed to a rapid onslaught from other cultures experience a cultural shock resulting in a high degree of mental and social stress.[1]
Understanding of mental health in different cultures
Conceptually, if we look at the ancient culture, there are four cultural streams that are prominently seen. The Indian, Egyptian, Roman and Chinese culture. One similar phenomenon observed regarding mental health problems in all of them is the impact of supernatural on the human mind. The understanding of illness also in different cultures interestingly has been perceived as an imbalance of humors leading to problems of mind and body. For example, the personality traits sat, raj and tam and the three humors, vat, pitt and kaph conceptualized in Indian subcontinent also correspond to theories of Chinese and Roman culture. All cultures developed independently, thousands of miles apart with very little communication. The similar thinking about mental health issues shows the similarity of human thoughts across cultures.
In India, mental health and psyche has been an area of exploration for centuries together, right from the vedic period, there has been a description of human mind, its functioning, consciousness and dynamics of human behavior.
There have been a sizeable number of studies which relate to the demographic factors, cultural factors influencing presentation of illness, diagnosis of the illness-culture bound syndromes and influence of the cultural factors and the belief system on psychopathology, stigma and discrimination towards the patient. An attempt has been made to critically look at the research on culture and psychiatry in different areas and their influence on the patient, his diagnosis and treatment.
Demographics
Trivedi JK et al.[3] in their study "Rapid urbanization - Its impact on mental health: A South Asian perspective" suggested that urbanization is affecting the entire gamut of population especially the vulnerable sections of society. Rapid urbanization has also led to creation of "fringe population" mostly living from hand to mouth which further adds to poverty. Urban population is heavily influenced by changing cultural dynamics leading to particular psychiatric problems like depression, alcoholism, and delinquency. Judicious use of resources, balanced approach to development, and sound government policies are advocated for appropriate growth of advancing economies of South-Asian region. Paralikar V et al.[4] while studying "Prevalence of clinically significant functional fatigue or weakness in specialty outpatient clinics of Pune, India." found that overall prevalence of such disorders is 5.02% with higher rates in dermatology and ayurvedic clinics and a notable (63.83%) female preponderance.
Presentation of symptoms in different cultures
Gautam and Kapur[5] in a study of psychiatric patients presenting with somatic complaints reported that more patients from Muslim ethnic group presented with somatic symptoms in South Indian population. Headache followed by nauseating sensation and vomiting were the prominent somatic complaints of the neurotic disorders. Gautam et al.[6] repeated the study in north Indian population and found that the predominant somatic complaint was constipation and feeling of gas in the abdomen.
Chaturvedi and Bhugra[7] reported that there has been a significant alteration in the concept of neurosis in most culture, with the relative abandonment of the term 'neurosis' and replacing the concept with that of common mental disorders, however, other conceptual equivalents of neurosis are seen in somatoform disorders, somatization and abnormal illness behaviour. Some traditional culture-bound neurotic syndromes and idioms of distress persist. Kulhara and Chakrabarti[8] studied "Culture and schizophrenia and other psychotic disorders" and observed that there is certain uniformity to the way schizophrenia presents globally; there are equally significant cultural differences. The outcome of schizophrenia appears to be better in developing, than developed cultures; reasons for this are far from clear, nevertheless, it can be safely assumed that culturally- determined processes, whether social or environmental, are partly responsible.
Jacob KS[9] reported in their study, "The cultures of depression." that there are many cultural issues that need to be resolved. Clinically, there is a need to look beyond symptoms and explore personality, life events, situational difficulties and coping strategies in order to comprehensively evaluate the role of vulnerability, personality factors and stress in the causation of depression. In a review, "Depression among women in the South-Asian region: The underlying issues.", Trivedi JK et al.[10] gave indications of specific health care needs of women in the region and suggested that mental health needs to be customized as per local needs and cultural sanctions.
Culture-bound syndromes
Sumathipala A et al.[11] in their study "Culture-bound syndromes: The story of dhat syndrome." explored the possibility of the presence of similar symptoms and syndromes in different cultures and historical settings. And concluded that the presence of similar symptoms and syndromes in different cultures and historical settings. Chaturvedi SK et al.[12] in their work, " Dissociative disorders in a psychiatry institute in India - A selected review and patterns over a decade" emphasized that unlike in the West, dissociative identity disorders were rarely diagnosed; instead, possession states were commonly seen in the Indian population, indicating cross-cultural disparity.
Pereira S et al.[13] in their review "Making sense of 'possession states': Psychopathology and differential diagnosis." presented clinical guidelines for a culturally sensitive assessment and management. Bhatia MS[14] in his study, "Compulsive spitting - A culture bound symptom "explored the possibility of compulsive spitting being a culture-bound symptom. Bhatia MS[15] also reported an analysis of 60 cases of culture bound syndromes.
Bhatia and Choudhary[16] described the contradictions in the diagnosis of hysteria in their paper "Hysteria - A chameleon or a fossil?"
Cultural attitude to treatment
Saravanan B et al.[17] in their paper "Assessing insight in schizophrenia: East meets West." concluded that the relationship between insight, awareness of illness and other clinical variables is similar in South India to elsewhere. However, the assessment of insight might have failed to capture locally accepted explanatory frameworks. Nunley M[18] in his study, "Why psychiatrists in India prescribe so many drugs?" offered the need to "sell" psychiatry as a legitimate kind of medicine by satisfying client expectations, and psychiatrists' relationship to other actors in India's pluralistic medical system, as factors that encourage a reliance on pharmaceutical or somatic interventions in psychiatric settings.
While describing her "Experiences with psychotherapy training in India." Hoch[19] tried to show how difficulties encountered not only in psychotherapy with Indian patients, but also in supervision of candidates in training for psychotherapy can be related to specific cultural patterns of personality development and social intercourse and, beyond this, traced back to their deeper roots in the traditional Indian world view. In their paper, "Treatment of mental disorders in India", Bagadia VN et al.[20] described the status and priorities of mental health in India. Rajkumar AP et al.[21] suggested that interventions after disaster should be grounded in ethno- cultural beliefs and practices and should be aimed at strengthening prevailing community coping strategies.
Phillips PA[22] did an exploratory study on dual diagnosis with staff perception of substance misuse among mentally ill of north India as the point of focus and reported that Dual diagnosis was seen as a common problem according to staff interviewed, although types of substance use reported were different than in western studies. Traditional substance use (the use of substances in distinct cultural, religious, and social settings that is not prohibited, such as khat or betel nut) also was reported as common among those with dual diagnosis.
Aggarwal NK[23] explored the identity, culture, and suffering with a Kashmiri Sikh refugee.
Belief system influencing course and outcome
Shankar BR et al.[24] while studying "Explanatory models of common mental disorders among traditional healers and their patients in rural south India", found that different terms, concepts and treatments were used by traditional and faith healers. 42.3% satisfied the International Classification of Diseases- 10 Primary Care Version criteria for Common Mental Disorders. Mixed anxiety depression was the most common diagnosis (40%). they concluded that an understanding of local patient perspectives of common mental disorders will allow modern medicine to provide culturally sensitive and locally acceptable health care.
Saravanan B et al.[25] explored "Belief models in first episode schizophrenia in South India" and concluded that patients with schizophrenia in this region of India hold a variety of non-medical belief models, which influence patterns of health seeking and are likely to be rated as having less insight.
Bhugra D[26] described "Sati: A type of non-psychiatric suicide" and illustrated cultural factors, which may be seen as contributing to the act of suicide. Loganathan and Murthy SR[27] studied "Experiences of stigma and discrimination endured by people suffering from schizophrenia" and found significant differences between rural and urban respondents. They concluded that mental health programs and policies need to be sensitive to the consumer need and to organize services and to effectively decrease stigma and discrimination. Gautam S et al.[28] in a prospective study carried out to find relevance of stigma in North Indian population reported that with advancement in treatment, the themes of stigma are changing. The tools available to study the stigma have become obsolete and a culturally relevant tool, Jaipur Stigma Questionnaire designed, standardised and validated in the given population revealed that segregation of mentally ill from the society and shame for consultation are fading themes of stigma in the present time. Stigma is important in making access to health care difficult. The culturally relevant issues leading to stigma in north Indian population are social distance, rejection, guilt and responsibility for illness.
Implications in psychotherapeutic process
In Indian thought, human behavior has been explored at length. In post-vedic period, in Upanishads, Bhagwad Gita, Yogic and ayurvedic literature abnormalities of human behavior have been described and the treatise has been emphasized mainly through psychic changes.[29] In India psychotherapy also needs to be based on cultural concepts and the prevailing belief system through centuries from generation to generation, which becomes more acceptable to the patient. If we accept psychotherapy as a interpersonal method of mitigating suffering, the process of change occurs in an individual through a psychotherapeutic relationship which has been described as the 'guru- chela relationship' in India, where in the wise offers advice to the pupil and helps him relieving the suffering. This has been observed in Buddhist and Jain traditions too.
Relevance to modern psychiatry
In the recent past there has been lot of research on use of many eastern techniques of healing in health sciences. Lot of emphasis is being laid on life style and health. Modern era and its increasing stresses call for stress management techniques and medicines devoid of side effects which increase the importance of alternative methods of medicine.
Scientific research on transcendental meditation programme has shown effectiveness of meditation on reducing neuroticism (Ander Tjoa) improving learning (Miskiman), improving academic achievements, prevention of alcohol (Shafii) and drug abuse (David Katz) There have been several reports on effect of transcendental meditation on reduction of anxiety, neuroticism (Jean Ross). Alexander and Schnieder reported comprehensive effects on neuroendocrine, psychological, social and spiritual factors related to substance abuse. Role of yoga in stress and sleep management, improving performance in sports and executives is being stressed recently. Prekshyadhyan a combination of meditation and relaxation technique has been found useful in improvement of concentration, memory and anxiety reduction in a study conducted at Jaipur by the author. Effectiveness of vipassana meditation as a therapeutic tool in psychological and psychosomatic illnesses has been reported by lyer and Flechman.
Some Ayurvedic combinations have been used as anti-anxiety and anti- depressants, reports of which are available from National Institute of Ayurveda, Jaipur. Vacha (Acorus calamus) and Jyotishmati (Celastrus Panniculatus) were found useful in treatment of depression (Bahetra). Unmad Bhanjan Ras a combination of 24 compounds was found to have anti- psychotic effect equivalent to chlorpromazine.
While communicating with cancer patients it was found by Gautam and Nijhawan,[30] that Indian patients tend to accept the diagnosis of cancer rather easily. The concept of death prevalent in Indian culture based on philosophy of Gita where soul is accepted as immortal and it is believed to transfer through death from one to another human/species plays a significant role in the easy acceptance of the diagnosis and the planning for the rest of the life.
The understanding of human psyche in vedantic model is more acceptable to Indian patients because of transfer of attitudes from generation to generation. Anecdotes from Bhagwat Gita as a psychotherapy of dying patient is virtually a tradition in Indian culture. Even now in many families when death is anticipated preaching of Lord Krishna stating that thoughts at the time of death determine the species of next birth help the individual to accept the death in a more gracious manner. The concept of "sthit pragna" (fLFkr izK) how a person can remain detached from pleasure and sorrow unaffected by losses and gains inculates peace in the mind. One of the Neeti Shlokas says. Xkrs "kksdks u drZO;s] Hkfo"; A uSofpUr;srA orZekusu dkysu orZ;fUrp foPk{k.kkAA
"It is not your duty to grieve the past nor should you worry about the future. Only he, who lives the present and thinks about the present is a wise man", can help a depressed patient worrying for a recent loss.
Similarly many other anecdotes from ancient literature like Ramayana, Mahabharata and later writings like Neeti Shlokas and Panchatantra can be very usefully employed in supportive psychotherapy. There is a need to re- explore this vast treasure of knowledge which may be culturally relevant and useful for Indian patients. What is needed is to make our patients aware of their hidden potentials as was done by Jamwant to Hanuman before going to Lanka in the epic of Ramayan. These ancient texts should be re-explored for models of conflict resolution, understanding psychopathology and attainment of self-realization.
CONCLUSION
Cultural factors influence understanding, presentation, diagnosis, management, course and outcome of mental illnesses. There is a need for culturally oriented modules of non-pharmacological management.
It would be appropriate to conclude with the words of Dr. Radhakrishnan: "India has seen empires come and go, has watched economic and political systems flourish and fade. It has seen these happen more than once. Recent events have ruffled but not diverted the march of India's History. The culture of India has changed a great deal and yet has remained the same over three millennia. Fresh springs bubble up, fresh streams cut their own channels through the landscape, but sooner or later each rivulet, each stream merges into one of the great rivers which has been nourishing the Indian soil for centuries."
REFERENCES
1. Rao VA. 'Culture and mental health', Broadcast talk from All India Radio, Madurai, 1987. 2. Trujillo M. Cultural psychiatry: A review of literature. 3. Trivedi JK, Sareen H, Dhyani M. 'Rapid urbanization - Its impact on mental health: A South Asian perspective'; PMID: 19742238 [In press] 4. Paralikar V, Agashe M, Oke M, Dabholkar H, Abouihia A, Weiss MG. Prevalence of clinically significant functional fatigue or weakness in specialty outpatient clinics of Pune, India. J Indian Med Assoc 2007;105:424-6, 428, 430. 5. Gautam SK, Kapur RL. Psychiatric Patients with somatic Complaints. Indian J Psychiatry 1977;19:75-80. 6. Gautam S. Psychiatric Patients with somatic complaints in a General Hospital Mental Health Clinic. (Abstract Published) Souvenir 2nd Annual Conference Rajasthan Psychiatric Society (Sep 11 and 12) Jaipur. 7. Chaturvedi SK, Bhugra D. The concept of neurosis in a cross-cultural perspective. Curr Opin Psychiatry 2007;20:47-51. 8. Kulhara P, Chakrabarti S. Culture and schizophrenia and other psychotic disorders. Psychiatr Clin North Am 2001;24:449-64. 9. Jacob KS. The cultures of depression.; Natl Med J India 2006;19:218-20. 10. Trivedi JK, Mishra M, Kendurkar A. Depression among women in the South-Asian region: The underlying issues. J Affect Disord 2007;102:219-25. Epub 2006 Nov 7. 11. Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes: The story of dhat syndrome. Br J Psychiatry 2004;184:200-9. 12. Chaturvedi SK, Desai G, Shaligram D. Dissociative disorders in a psychiatry institute in India - a selected review and patterns over a decade. Int J Soc Psychiatry 2009 Sep 17. PMID: 19762410 [PubMed - as supplied by publisher] 13. Pereira S, Bhui K, Dein S. Making sense of 'possession states': Psychopathology and differential diagnosis. Br J Hosp Med 1995;53:582-6. 14. Bhatia MS. Compulsive spitting—a culture bound symptom. Indian J Med Sci 2000;54:145- 8. 15. Bhatia MS. An analysis of 60 cases of culture bound syndromes Indian J Med Sci 1999;53:149-52. 16. Bhatia MS, Choudhary S. Hysteria—a chameleon or a fossil? Indian J Med Sci 1998;52:227- 30. 17. Saravanan B, Jacob KS, Johnson S, Prince M, Bhugra D, David AS. Belief models in first episode schizophrenia in South India. Soc Psychiatry Psychiatr Epidemiol 2007;42:446-51. Epub 2007 May 14. 18. Nunley M. Why psychiatrists in India prescribe so many drugs. Cult Med Psychiatry 1996;20:165-97. 19. Hoch EM. Experiences with psychotherapy training in India. Psychother Psychosom 1990;53:14-20. 20. Bagadia VN, Shah LP, Pradhan PV, Gada MT. Treatment of mental disorders in India. Prog Neuropsychopharmacol 1979;3:109-18. 21. Rajkumar AP, Premkumar TS, Tharyan P. Coping with the Asian tsunami: Perspectives from Tamil Nadu, India on the determinants of resilience in the face of adversity. Soc Sci Med 2008;67:844-53. Epub 2008 Jun 16. 22. Phillips PA. Dual diagnosis: An exploratory qualitative study of staff perceptions of substance misuse among the mentally ill in Northern India.; PMID: 18058336 [PubMed - indexed for MEDLINE] 23. Aggarwal NK. Exploring identity, culture, and suffering with a Kashmiri Sikh refugee. Soc Sci Med 2007;65:1654-65. Epub 2007 Jul 25. 24. Shankar BR, Saravanan B, Jacob KS. Explanatory models of common mental disorders among traditional healers and their patients in rural south India. Int J Soc Psychiatry 2006;52:221-33. 25. Saravanan B, Jacob KS, Johnson S, Prince M, Bhugra D, David AS. Belief models in first episode schizophrenia in South India. Soc Psychiatry Psychiatr Epidemiol 2007;42:446-51. Epub 2007 May 14. 26. Bhugra D. Sati: A type of nonpsychiatric suicide. Crisis 2005;26:73-7. 27. Loganathan S, Murthy SR. Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian J Psychiatry 2008;50:39-46. 28. Gautam S, Gupta ID, Jain N, Singh H. Stigma Revisited; submitted for publication (forthcoming) to Asian Journal of Psychiatry. [In press] 29. Gautam S. Presidential address: Mental health in ancient India and its relevance to modem psychiatry. Indian J Psychiatry 1999;41:5-18. 30. Gautam S, Nijhawan M. Communicating With Cancer Patients, Br J Psychiatry 1987;150:760-4.
Shiv Gautam Department of Psychiatry Sr. Professor, Superintendent, Addl. Principal, Nikhil Jain 2nd yr. resident doctor, Psychiatric Centre SMS Medical College Jaipur - 302 004, India 52 Military psychiatry in India
Brig H. R. A. Prabhu
ABSTRACT
Military personnel, because of the unique nature of their duties and services, are likely to be under stress which at times has no parallel in civilian life. The stress of combat and service in extreme weather conditions often act as major stressors. The modern practices in military psychiatry had their beginning during the two World Wars, more particularly, the IInd World War. The GHPU concept had the beginning in India with military hospitals having such establishments in the care of their clientele. As the nation gained independence, many of the military psychiatrists shifted to the civil stream and contributed immensely in the development of modern psychiatry in India. In the recent years military psychiatry has been given the status of a subspecialty chapter and the military psychiatrists have been regularly organizing CMEs and training programs for their members to prepare them to function in the special role of military psychiatrists.
Key words: Military Psychiatry, India, psychiatric centres
INTRODUCTION
The primary goal of Armed Forces of any country is to guard the nation against the external enemy. In the peace time role they also assist the civil administration in times of natural calamities at least in the initial part, because of their readiness to attend any such emergencies. The Armed Forces, because of the rigorous standards used in selection, ensure that only physically and mentally robust are recruited. The military training imparted ensures that the young raw recruit coming from a diverse socio-cultural environment gets transformed in to a battle worthy and disciplined soldier. Life in the Armed Forces exposes the personnel to such environments which many a times have no parallel in the civilian life- like living in isolated posts of extreme high altitudes, often being exposed to the life threatening combat environment. The family life of a soldier can get affected because of long periods of separation due to call of duty. Mental health issues assume importance in the backdrop of such issues. However, the working style of the Armed Forces ensures that the troops are on the constant watch of the immediate superiors almost on a daily basis so any deviation of behavior is likely to be noticed early and brought to the attention and taken care of. The military services have a well knit, time tested psychiatric service as part of their medical services to deal with the problems.
THE PAST
Pre World War II scenario
After the East India Company of the British established their base in India in the eighteenth century, as early as 1745, the first asylum for the care of British Soldiers, was established at Bombay as a part of the "Hospital" at Marine Yard. In 1795, the first hospital for mentally ill Indian sepoys was established in Monghyr, Bihar, which was subsequently disbanded in 1831.[1] In 1918 Col Owen Berkeley-Hill established European Mental Hospital at Ranchi and in 1922 Lt Col Lodge Patch at Lahore. The advent of World War II led to significant expansion of services for psychiatric services for the soldiers.[2]
During World War II and the post-independent era
The establishment
At the outbreak of war there were only four specialists in psychiatry for the whole of troops in India. Because of their small number, most of the time the specialists recommended treatment to the patients with out seeing them and only on the basis of the reports sent to them.[2] The massive troop build-up, as war advanced, led to the establishment of service hospitals for the casualties and two specialists for mental diseases were authorized to the war hospitals. By August 1942 a pool of 10 specialists were created for peace hospitals which was increased to 31 by May 1943. By 1945 the strength of psychiatrists had increased to 86.[3,4] General duty medical officers (GDMO) with some training in psychiatry augmented the psychiatric services when the number of psychiatrists increased during war the senior psychiatrists were appointed as Advisors and they supervised the work of the other psychiatrists. While in the operational areas, particularly by 1944, there were psychiatrists posted up to Corps and Divisional level in Army and the psychiatrists established 'Exhaustion centers' to treat cases if battle exhaustion. Training
Even though most GDMOs did not like to undergo training in psychiatry, those who were interested were exposed to training under senior qualified psychiatrists for three to four months after which they were posted as graded specialists. The training was mostly a hands-on experience of writing case histories, patient examination and diagnosing and suggesting treatment under the supervision of senior psychiatrist. The training used to be conducted at few centers like Calcutta and Lucknow. After many efforts it was found that training for a period of nine months to one year was considered the most efficient. Discussions on common medical problems and conferences were arranged.
Psychiatric centers
All the psychiatric centers of the military hospitals, both in war and peace, had been delivering services on the lines of General Hospital psychiatric units (GHPU). During war the psychiatric patients got treated in the psychiatric centers of different war time hospitals known as Indian Base General Hospitals (IBGH). There was separate authorization of beds for the Indian and British troops in different hospitals. The former, with 450 beds in three hospitals and the latter a total of 553 beds in five hospitals. Capt BL Chandorkar, who had served initially as MO, then as a trained psychiatrist in hospitals in Iraq and later at Alipore (Calcutta) and Dimapur has documented his war time experience as a psychiatrist. [5] After war he shifted to civil stream and finally served as Superintendent of mental hospitals of Thane and Yerwada.
A standard psychiatric ward had 25 beds and larger psychiatric centers had multiples of these. In July 1945, a 1000 bed psychiatric hospital was established at Jalahalli in Bangalore, which was disbanded later. In the large psychiatric centers one used to be the open ward where neurotic patients and quiet psychotic patients were kept. Psychotic patients mostly consisted of patients of schizophrenia and were kept in closed wards. Drugs used were hypnotics like bromides, chloral hydrate, phenobarbitone and paraldehyde. There was liberal use of paraldehyde orally or in injectable form to control aggression and one could always smell paraldehyde on entering such wards. Strait jackets and physical restraint to the bed were used too. Stable or less disturbed patients were used in making beds, cleaning ward utensils, fetching food etc. Recreation, as outdoor and indoor games, was generally available.
The psychotics were generally removed from service while neurotics who recovered from the symptoms were sent back to duty. Eventually most of them relapsed and were sent out of service. The staffing of the psychiatric centers was with mental health orderlies (MNO). Till 1943 there were about 100 British MNOs. Subsequently, Indian MNOs took over with which the environment in the psychiatric wards improved. The first ECT machine was brought to the country by Brig Bennet and it was used at Military Hospital Karachi. The machine was later used at Ranchi and Pune. By 1945 several military hospitals had ECT machines.[3]
Selection boards
An additional task that the psychiatrists were involved was in the selection of cadets for the Armed Forces. Each of the five selection boards - four for Army at Rawalpindi, Jabalpur, Calcutta, Bangalore and one for Navy at Lonavala had a psychiatrist on the panel and their work was supervised by an Advisor in Psychiatry at the Directorate of Selection Boards.[3]
The stalwarts
After leaving service, many of the military psychiatrists shifted to civil stream and contributed to the development of psychiatry in India. In 1947, Indian Psychiatric Society was established mainly due to the efforts of Major RB Davis. [5] Other notable names in this regard were Lt Col M R Vacha, Maj G A Bhagwat, Maj Vidyasagar, Capt B L Chandorkar, Maj KC Dube, Maj Je Dhunjeebhoy, Lt Col G R Parasuram. Col Kirpal Singh was the first senior psychiatrist of military services of Indian Origin in the post independent era. He joined military service in June 1941 and served till June, 1968. He was Professor and HOD Psychiatry at AFMC, Pune, from 1964-66 and later Senior Advisor in Psychiatry with Army Medical Corps as well as Defence Institute of Psychological Research at Delhi from 1966-68. He had a large number of original research papers in both national and international professional journals and was recipient of several fellowships and awards of professional bodies. His contributions to the development of psychiatry in India and military psychiatry in particular are immense.
THE CONTEMPORARY
In the last three decades several military psychiatrists contributed to the growth of military psychiatry and many of them had been also active in the civil arena. They were Surg Rear Adm TB D'Netto, Brig SB Chatterjee, Brig RN Bhattacharya, Col GR Golecchha, Air Cmde IC Sethi, Maj Gen BP Singh, Surg Cmde MA Basit, Brig PK Chakraborty, Brig MB Pethe, Maj Gen PS Valdiya, Col DS Goel, MSV Kama Raju, Brig Sudarsanan, Brig D Saldanha among many others. Most of them had been professors of psychiatry at the Armed Forces Medical College. Some of them had also been presidents of Indian Psychiatric society. Col DS Goel, after retirement, had a stint as a National Consultant at the Directorate General of Health Services, at Ministry of Health and Family Welfare, Government of India.
In 1997, 50 years after the inception of the Indian Psychiatric Society, Military Psychiatry was recognized as a subspecialty chapter. Ever since, the chapter has been organizing CMEs, seminars and presentations both independently as well as part of the Annual National conference of the IPS. On 21 September, 1997, Brig D Saldanha, then a psychiatrist at Military hospital Kirkee, Pune, organized the first CME on Military Psychiatry attended by large number of service as well as civil psychiatrists. Since then the CME programs have been held on a regular basis in various military stations. Armed Forces Medical College is the only medical college of the Armed Forces and a tri-service Category A training establishment, which undertakes undergraduate training for the future military doctors in psychiatry as well as post-graduate training in Psychiatry and military psychiatry.
Military psychiatrists of Army have been working in different and varied environments all over Indian subcontinent including border areas, areas affected by counter insurgency or those receiving soldiers in inhospitable high altitude terrains, jungles or desert areas. Those working in Navy and Air Force have been rendering their services for troops working at sea and in air environments. Original research has been conducted in to stress related to combat both in high intensity and low intensity counter insurgency operations, life in extreme high altitudes, life at sea, submarine environment and in flying personnel by the psychiatrists of the three services. Most such research in their areas of specialized work in the services is done under the auspices of the Armed Forces Research establishment and gets published in service medical journals.
CONCLUSION
The foundation for Military Psychiatry in India was firmly laid during the few years of World War II. The contributions of service psychiatrists in the early years of inception of psychiatry in India have been substantial. With the unique nature of the working environments, the problems that the soldiers, sailors and air warriors face the work of military psychiatrists and the DRDO is of different kind and the unique research data brought are most of the time away from public domain due to security reasons. They find their application in the Armed Forces healthcare delivery. Military psychiatry, having evolved as an independent subspecialty, has come of age with lot of innovations and improvements in psychiatric services in the Armed Forces. REFERENCES
1. Crawford DG. A History of The Indian Medical Service 1600-1913.Vol. 2.. London: W. Thacker and Co; 1914. p. 395-417. 2. Raju MS. Military Psychiatry in India Genesis and early development: In Souvenir, CME on Military Psychiatry,1997 "Towards the next Millennium" at Military Hospital . Kirkee, Pune on 21 Sep, 1997. p. 16-21. 3. Raina BL, editor. Psychiatry in the India Command. Fourteenth Army and ALFSEA. Official History of the Indian Armed Forces in the Second World War 1939-45. Medical Services, Medicine Surgery and Pathology 1955. p. 335-87. 4. Raina BL, editor. Mobilisation Training IAMC. Official History of the Indian Armed Forces in the Second World War 1939-45. Medical Services, Administration. Combined inter Services Historical Section, India and Pakistan, 1953. p. 150-220. 5. Chandorkar BL. Reminiscences of Military Psychiatry in World War-II: In Souvenir, CME on Military Psychiatry, 1997 "Towards the next Millennium" at Military Hospital Kirkee, Pune on 21 Sep 1997. p. 10-5.
Brig H. R. A. Prabhu Department of Psychiatry AFMC, Pune, India 53 Research on antipsychotics in India
Ajit Avasthi, Munish Aggarwal, Sandeep Grover, Mohd Khalid Rasheed Khan
ABSTRACT
Antipsychotic as a class of medications became available for treatment of various psychiatric disorders in the early 1950's. Over the last 60 years many antipsychotics have become available. In line with the west, Indian researchers have evaluated the efficacy of antipsychotics in various conditions. Additionally, researchers have also evaluated the important safety and tolerability issues. Here, we review data originating from India in the form of drug trials, effectiveness, usefulness, safety and tolerability of antipsychotics. Additionally, data with respect to other important treatment related issues is discussed.
Key words: Antipsychotic, research, India
INTRODUCTION
When one looks at the history of psychiatric treatments, prior to availability of electroconvulsive therapy (ECT), measures like magic, restraints, blood letting, emetics, purgatives, surgical operations on various organs, removal of foci of infections, vaccines and endocrines were tried as treatment options for schizophrenia. Therapies like insulin coma and electroconvulsive therapy became available. [1] However, the era of pharmacotherapy for treatment of schizophrenia started with use of chlorpromazine by Delay and Deniker for the treatment of patients suffering from schizophrenia in early 1950's. Over the next half century, a large number of drugs have been evaluated and marketed as antipsychotics. This class of drugs also helped in understanding the neurobiology of schizophrenia to some extent. This class of drug has also changed the attitude of the clinicians towards the expected outcome of the disorder.
India, as a country was not isolated from all these developments. Over the years many classes of antipsychotics have become available in India, some of which have stood the test of time and are still in use and some are no more marketed or are no more favorite of the clinicians. Research focusing on the usefulness of psychotics in India has more or less followed the trends in the West; however, some of the newer antipsychotic drugs which are currently marketed have not been evaluated as thoroughly as others. The pharmaceutical industry and the policy of the government have ensured that these medications are available at a reasonable price.
This review focuses on research done on various anti psychotics in India. For this a thorough internet search was done using key words like India, antipsychotics, name of each antipsychotic, efficacy, effectiveness, usefulness, tolerability, side effects, metabolic syndrome, weight gain, prescription, cost in various combinations. Various search engines like PUBMED, GOOGLE SCHOLAR, SCIENCEDIRECT, SEARCH MEDICA, SCOPUS, and MEDKNOW were used. In addition, a through search of all the issues of Indian Journal of Psychiatry available online was done. Hand search of some of the missing issues was also attempted and this yielded a few more articles. We have excluded review articles which we felt did not reflect the Indian scenario to a large extent or did not cover the available Indian data. Data from the animal studies that originated in the form of case reports and studies published only as abstract have not been included.
EFFICACY OF ANTIPSYCHOTICS IN SCHIZOPHRENIA
Efficacy of first generation antipsychotics in schizophrenia [Table 1]
Twenty eight studies which have evaluated the efficacy of first generation oral antipsychotics in schizophrenia have been published.[2-29] Of these, most have been open trials, some have been double blind randomized controlled trials and only a few have compared active drug with placebo. Some have also followed the cross over design with intermediate drug free period. Some of the initial trials included subjects who had not responded to previous pharmacological or somatic treatment and were suffering from chronic schizophrenia. Further, some studies have included treatment refractory subjects and others have recruited only those subjects who responded to some medication in the past. The sample size has varied from 15 to 145 subjects and the duration of trials have varied from eight days to six months, but most have evaluated the subjects in 4-12 weeks. Most of the trials included subjects with acute symptoms, however, one trial evaluated the efficacy of penfluridol and haloperidol in the maintenance phase and another included subjects who, on baseline, had shown at least 50% response on BPRS to the previous antipsychotic medication.[29]
Except for some of the trials in the 1960s and early 1970s, the efficacy and side effects were measured on some rating scales. All these trials have not Table 1: Efficacy of First generation antipsychotics in schizophrenia
Schiz- Schizophrenia; DBPCT-Double blind placebo controlled trial; PCPZ- Prochloperazine; PBO- Placebo; EPS-Extrapyramidal symptoms; TRZ- Thioridazine; S/ E- side effect; FFP- Fluphenazine; TPZ- Thioproperazine; CVS- Cardiovascular system; RCT- Randomized Controlled Trial; MMPI- Minnesota Multiphasic Personality Inventory; TAT- Thematic Apperception Test; TFP- Trifluoperazine; UCPZ- Unichlorpromazine; THF- Trihexyphenidyl; HPL- Haloperidol; CPZ- chlorpromazine; PSSR- psychotic symptom severity rating chart; DBRCT- double blind randomized controlled trial; GI- Gastrointestinal; LFT- Liver Function Test; RFT- Renal Function Test; DBCT- double blind controlled trial; FFX- Fluphenthixol; TFD- Trifluperidol; QPSS- Quantification of psychotic symptom severity; WBRS- Wing's behaviour rating scale; CNS- Central Nervous System; PMZ- Pimozide; MSQ-mental status questionnaire; SMSQ- Special Mental Status Questionnaire; WPRS- Wittenborn Psychiatric Rating Scale; LFFMBS- L-M Fergus Falls Behavior Schedule; BPRS- Brief psychiatric rating scale; Li- lithium; MBPRS- Modified Brief psychiatric rating scale; CGI-S - clinical global impression Severity; SAPS- Scale for Assessment of Positive Symptoms, SANS- Scale for Assessment of Negative Symptoms; SAS- Simpson and Angus Rating Scale for Extrapyramidal side effects. used the dropouts in their final analysis of data. Data from all these trials can be summarized as: Typical antipsychotics are useful for treatment of schizophrenia, typical antipsychotics are more efficacious than placebo in the treatment of schizophrenia, improvement is seen more in paranoid and catatonic symptoms, aggression and less so in depressive symptoms; addition of trihexyphenidyl doesn't reduce the efficacy of antipsychotic like trifluperazine and extrapyramidal symptoms are common with typical antipsychotics.
Efficacy of injectable depot first generation antipsychotics in schizophrenia [Table 2]
Nine trials have evaluated the efficacy of depot antipsychotics in schizophrenia.[30-38] Some of these trials have just focused on short term outcome (2-4 weeks), whereas others have evaluated the outcome after six months. One trial followed up the subjects for 1-3 years.[37] In most of these trials subjects included were those who were non-complaint to oral medications and had frequent relapse. All these were open label and did not use a comparator group, except for the trial by Bagadia et al.[36] that compared subjects on fluphenazine decanoate with subjects who has been receiving either chlorpromazine or trifluperazine. All these studies have shown that depot antipsychotics are useful in the management of schizophrenia in acute phases and also for maintenance treatment.
Efficacy studies of first generation antipsychotics vs. electroconvulsive therapy/electroconvulsive therapy and first generation antipsychotics in schizophrenia [Table 3]
Thirteen studies have compared typical antipsychotics with either electroconvulsive therapy (ECT) alone or a combination of ECT and typical antipsychotic medication.[1,39-50] All studies have specified the diagnosis as schizophrenia, except for one study, in which the diagnosis was mentioned as functional psychosis.[45] A common theme which emerges from these studies is that typical antipsychotic, alone or when used in combination with ECT, produces similar response rate in short term, but addition of ECT leads to a faster response. The only study which evaluated the efficacy of ECT and chlorpromazine in treatment resistant schizophrenia (TRS) showed that augmentation with ECT in TRS may be a worthwhile option.[50]
Efficacy of centbutindole [Table 4]
Centbutindole was developed by Central Drug Research Institute, Lucknow; it has been evaluated in four trials and has been compared with trifluperazine, haloperidol and risperidone (see Table 5 for this trial).[51-54] These studies
have shown that centbutindole is as efficacious as haloperidol, trifluperazine and risperidone in the treatment of schizophrenia.
Efficacy studies of second generation antipsychotics in schizophrenia [Table 5]
Twenty studies have been published on evaluation of the efficacy/effectiveness of second generation antipsychotics in schizophrenia.[54-73] Of these trials, 11 have reported the efficacy of risperidone, five of clozapine, two of olanzapine, two of aripiprazole and one of quetiapine. Some of these studies have also evaluated different doses of the same medications and some others have evaluated the dosing schedule. All these trials have included subjects diagnosed as schizophrenia on the basis of DSM-IV or ICD-10 except for Agashe et al.[58] who used DSM-IIIR criteria. All these trials have used standard instruments to assess the efficacy and side effects. The sample size has varied from 30 to 606 and the duration of these trials have been six weeks to four months except for one trial which evaluated the outcome on risperidone at one year[61] and two studies, which followed up subjects on clozapine for 20 months and three years respectively.[66,69] All the studies on risperidone have shown that it is efficacious in short term. Studies which have compared risperidone with other antipsychotic have shown it to be more efficacious than quetiapine but as efficacious as haloperidol and centbutindole. Agarwal and Chadda[64] demonstrated that there was no difference in efficacy of once daily dose versus twice daily dose of risperidone. The study which followed up the subjects on risperidone for one year showed that compared to haloperidol, more subjects on risperidone had better social functioning, productivity and education and significantly fewer patients had suicidal ideation or attempts and needed rehospitalization.[61] Srivastava et al.[62] showed that half of the schizophrenia subjects in India require 3-4 mg/day of risperidone and another one-third improve with dose ranging from 1-2 mg/ day. All the studies which have evaluated clozapine have done so in TRS cases and have reported it to be useful in both short and long term. In the study by Avasthi et al.[65] olanzapine was found to be as efficacious as haloperidol on PANSS. Additionally olanzapine was found to be better than haloperidol in reducing associated depressive and anxiety symptoms. Sarin et al.[68] reported no difference in efficacy of 10 and 15 mg/day of aripiprazole.
Efficacy of antipsychotics in other disorders: mania [Table 6]
Some of the older studies included a few subjects with mania. Three studies in the early 60s included very few subjects in the open label design studies and reported efficacy of haloperidol, thioridazine and thioproperazine in the treatment of mania.[4,6,8] One study included only one case of treatment
refractory mania and showed that oral fluphenazine was not useful in such subjects. [5] Another study evaluated the efficacy of zuclopenthixol in management of 25 cases of mania. This study did not specifically report the efficacy of zuclopenthixol in mania, but irrespective of the diagnosis the reported outcome suggests that zuclopenthixol for eight weeks was useful.[74]
However, in the recent trials, atypical antipsychotics have been evaluated in large samples in double blind placebo control trials and the outcomes have been measured using standard instruments. In the study by Khanna et al. [75] risperidone was found to be significantly better than placebo at weeks 1 and 2 and 3 (total YMRS: P , 0.01). Another multicentric trial, which included subjects from India too, showed that both risperidone and haloperidol were better than placebo; however, there was no difference in the efficacy of risperidone and haloperidol.[76] At three weeks, more patients were treatment responders (.50% reduction in YMRS total scores) among those treated with risperidone (48%) or haloperidol (47%) than placebo (33%). The difference between risperidone and placebo was significant (P , 0.01). At 12 weeks, the response rate was maintained in almost all subjects who responded at three weeks and additionally more than 80% of the subjects who did not respond (reduction of .50% in the YMRS total score) to risperidone or haloperidol at three weeks but continued the medications responded at 12 weeks.
Acute psychosis [Table 7]
Four studies have reported the efficacy of antipsychotics in the management of acute psychosis, of which three have specified that the trials included subjects with acute and transient psychosis,[60,74,77] while another trial mentioned the diagnostic category only as acute psychosis.[78] Trial by Agarwal and Sitholey[77] involved children and adolescents presenting with acute and transient psychosis and is discussed later. These studies suggest that thioproperazine is better than chlorpromazine and there is no difference in short term efficacy of risperidone and haloperidol in acute and transient psychosis. As mentioned earlier Fernandes et al. [74] did not specifically report the outcome in acute and transient psychosis, however, irrespective of the diagnosis the reported outcome suggests that zuclopenthixol for eight weeks was useful.
Anxiety
Studies in 1970s and 1980s evaluated the efficacy of low dose haloperidol,[79] flupenthixol,[80] trifluperidol,[81] pimozide,[82] prochlorperazine,[83] trifluperazine[84] in various anxiety states and
reported these to be efficacious. The study which used pimozide compared it with chlordiazepoxide and reported it to be useful, but inferior to chlordiazepoxide.[82] The study which compared trifluperazine and chlordiazepoxide combination with prochlorperazine reported the latter to be better.[83]
Agitation and violence
Two studies have evaluated the role of antipsychotic in violent and agitated subjects attending the psychiatry emergency settings. In a randomized controlled trial, Alexander et al. [84] compared the efficacy of injectable lorazepam and a combination of injectable haloperidol and promethazine and reported that after four hours of the injection, 96% of the subjects in both the groups were tranquil or asleep. However, in terms of being asleep, 76% of the subjects given haloperidol-promethazine were asleep compared to 45% of subjects in the lorazepam group. The haloperidol-promethazine combination also produced a faster onset of tranquillization/sedation and more clinical improvement over the first 2 h. Neither intervention differed significantly in the need for additional intervention or physical restraints, subjects absconding, or adverse effects. In another randomized study from the same centre, Raveendran et al. [85] compared the efficacy of intramuscular olanzapine with intramuscular haloperidol plus promethazine in 300 subjects and reported that both treatments led to similar proportions of subjects being tranquil or asleep at 15 minutes (olanzapine-87%, haloperidol plus promethazine-91%) and 240 minutes (olanzapine-96% and haloperidol plus promethazine-97%). However, compared to those given haloperidol plus promethazine, more subjects in the olanzapine group required additional drugs over four hours (21% vs. 43%). Adverse effects were uncommon with both treatments.
Delirium
Only a small case series of seven cases reported that risperidone is effective in the management of delirium and it is well tolerated by these subjects.[86]
Delusional disorders
Good response to antipsychotics like trifluperazine, haloperidol and chlorpromazine was reported in cases of delusional parasitosis.[87] In their study on delusional disorder, Grover et al.[88] found that best response was seen with risperidone, followed closely by pimozide. Of the 20 subjects treated with risperidone, six were considered to have good response (.75% reduction in symptoms) and nine were considered to have partial response (.25 but ,75% reduction in symptoms). Of the 18 subjects treated with pimozide, four qualified for good response and six as partial responders.
Use of Antipsychotic in Children and Adolescents [Table 8]
Seven studies have evaluated the efficacy of various antipsychotics in childhood disorders or childhood/adolescent onset disorders. Studies done in 1960s and early 70s evaluated the role of antipsychotics primarily in the behavioral problems in children with epilepsy/epilepsy and mental retardation and have shown that trifluperazine, prothipendyl and trifluperidol are useful but fluphenazine is ineffective. One small study evaluated the usefulness of clozapine in childhood onset schizophrenia.[91] A study which evaluated the role of risperidone in autism showed promising results[92] and another study demonstrated the efficacy of olanzapine in childhood/adolescent onset acute and transient psychosis.[77] However, the studies which used olanzapine and risperidone showed that these drugs lead to reasonable weight gain, which may be cause of concern.
RESEARCH ON OTHER TREATMENT RELATED ISSUES
Pharmacogenomics
With increasing interest in the role of genetic factors in treatment response and side effects of medications, studies from India have tried to address the genetic links of tardive dyskinesia, treatment response and severity of psychopathology.[93-96] However, the findings are preliminary and inconclusive. Tiwari et al.[93] evaluated the role of six single nucleotide polymorphisms (SNP) in tardive dyskinesia and showed that CYP1A2 1545 C. T SNP was associated with TD (P 5 0 .03) and schizophrenia (P 5 0 .04), but the association was rendered insignificant after corrections for multiple comparisons. Vijayan et al.(2007)[94] studied various alleles, genotypes, haplotypes and their linkage disequilibrium and observed that H313HTT genotype was associated with schizophrenia and TaqIB1B1 genotype was significantly associated with higher psychopathology score. Subjects with H313HCC, TaqIA2A2 and Taq1D1D1 had higher mean improvement scores. Distinct shift in the linkage disequilibrium pattern of responder and non responder group was observed. Thomas et al.[95] reported that average olanzapine dose, baseline weight and dopamine receptor D-4 (DRD4-120 bp) duplication marker have significant association with the efficacy index. Gupta et al.[96] reported significant allelic associations of two SNPs (rs4633 and rs4680) with drug response.
Predictors of Treatment Response
A study reported that subjects, who showed initial dysphoric response to a
test dose of neuroleptic, later respond poorly to the neuroleptics.[97]
Prescription Patterns
A few studies have evaluated the antipsychotic prescription patterns from India. In one of the early studies, Khanna et al. [98] evaluated the psychotropics drug prescription pattern in chronic long stay patients at Ranchi and compared the prescription trends in 1984 and 1988. Most of the patients whose prescriptions were reviewed were suffering from schizophrenia. More than one antipsychotic medication was prescribed to 13% in 1984, which fell down to 7% in 1988. Further it was seen that very few patients received anticholinergic agents and the use of benzodiazepines increased over the years (4% in 1984 and 10% in 1988), which authors attributed to development of distressing tardive dyskinesias over the years. In an evaluation of prescriptions at discharge of patients with schizophrenia, Padmini Devi et al.[99] reported that risperidone was the most commonly prescribed antipsychotic (56.17%), followed by olanzapine (21.34%) and quetiapine (3.93%). Typical antipsychotics were used only in 15.73% of cases and polypharmacy (concurrent use of more than 1 antipsychotic) was seen in 9% of cases. In another study from Jammu, Shanwey et al.[100] evaluated the prescription of 270 outpatients, and reported that fixed dose formulation of trifluperazine, chlorpromazine and trihexyphenidyl (parkinforte) was used in 45.4% of cases followed by chlorpromazine[36.3%] and quetiapine [34.5%]. The authors also found that typical antipsychotics were used in 82.72% of cases and polypharmacy was seen in 72.72% of cases. Dutta et al.[101] evaluated the prescription patterns in 118 stable schizophrenia subjects and reported that on an average 2.8 medications were prescribed to each subject and olanzapine was the most commonly prescribed antipsychotic followed by haloperidol and risperidone. About half of the subjects were receiving more than one antipsychotic. All these findings suggest that antipsychotic prescriptions vary from centre to centre and possibly have changed over the years.
In a recently conducted survey, Grover and Avasthi[102] found that the three most commonly prescribed antipsychotics by Indian psychiatrists were risperidone, olanzapine and haloperidol. Typical antipsychotics comprise 25.15% of all prescriptions and in about 22.36% of cases the psychiatrists were using more than one antipsychotic in the same patient. Another survey specifically assessed the prescribing practices of clozapine; only 28% of psychiatrists reported that their prescription of clozapine was guided by their knowledge about the efficacy of clozapine. Majority of the psychiatrists opined that clozapine leads to symptom reduction to the extent of 40 to 70%, and the average dose required for stabilization was between 75 to 300 mg/day. Only 16% of psychiatrists preferred to combine clozapine with other antipsychotics. In terms of blood monitoring, 80% of the psychiatrists monitored the blood counts weekly in the first month of therapy and then once monthly for next 6 months and further monitoring was done as per the need.[103]
Treatment continuation, compliance and attitude towards treatment
Khanna et al.[104] reported that 31% of the subjects with schizophrenia do not keep their appointment for detail evaluation after initial evaluation in the walk-in clinic. The authors also reported that 32% of the subjects stop attending the clinic after initial detailed workup and diagnostic clarification. In another study from the same center, Kulhara et al.[105] reported that 25% of schizophrenia subjects do not come for follow-up after six months of detailed workup and diagnostic clarification and 23% of subjects with schizophrenia don't seek any medical help in next five years. Murthy et al.[106] studied a mixed group of patients (which included subjects of psychosis also) and reported that duration of illness more than six months, residence at a distance of more than 50 kilometers from the hospital and psychiatric diagnosis other than functional psychosis favored treatment discontinuation. Ponnudurai et al.[107] evaluated the treatment adherence in 111 cases of psychotic illness (mostly schizophrenia) by Ferric Chloride reagent test to look for excretion of phenothiazine in urine and reported non-adherence in 19% of subjects. In another interesting study Srinivasan and Thara[108] reported that history of noncompliance with oral medication was seen in about 58% of patients during the course of their illness and half of these subjects were given oral medications at least once without their knowledge by the family members under the psychiatrist's advice. It was seen that spurious administration of antipsychotic leads to reduction in symptoms in 91% of subjects given medications in this way and helps to convince the patient to take oral medications subsequently. Half of the caregivers who participated in the study felt that spurious administration of antipsychotic was the right action under the circumstances. In a recent study, Baby et al.[109] reported rates of non-compliance with medication to be 38.7% in subjects with schizophrenia. The authors also reported that a majority of the patients and family members had a positive attitude towards medication and treatment. Further, family members are able identify the compliance status of the patients and the reasons for the noncompliance better than the patients. The factors which had significant influence on the medication compliance included perceived daily benefit from medication, positive relationship with the psychiatrist, pressure from the family and health system and positive family belief towards illness and treatment. The significant reasons for noncompliance are no perceived daily benefit from medications, difficulty in gaining access to treatment and medications, financial obstacles, embarrassment or stigma related to treatment and medications and medicines currently not perceived as necessary. Besides attitude, other factors which are significantly associated with noncompliance include lower educational status, rural area of stay, adjustment difficulty with family and spouse, previous history of non-compliance, poor insight into illness, higher positive PANSS score. Past history of hospitalization was associated with better compliance with medications.
Impact of antipsychotics on disability
A recently published study, which compared three groups of community dwelling subjects with schizophrenia, showed that mean disability scores remain virtually unchanged in those who remained untreated, but showed a significant decline (indicating decrement in disability) in those who continued to receive antipsychotics and in those in whom antipsychotic treatment was initiated. The proportion of patients classified as 'disabled' declined significantly in the treated group, but remained the same in the untreated group.[110]
Costs
A few studies have evaluated the cost of antipsychotics per se and cost of management of schizophrenia. Girish et al.[111] found that antipsychotic drugs are affordable and comparable to drug treatment costs of other physical illnesses. They found the monthly cost of treatment with chlorpromazine was Rs.55, an equivalent dose of trifluperazine amounted to Rs.25/month, risperidone Rs.60 and clozapine Rs.225 per month. They also concluded that although antipsychotic drugs are affordable, the other costs associated with treatment make them more expensive, like co-prescribed antiparkinsonian agents, antidepressants, anxiolytics etc. Sarma[112] showed that cost of one outpatient visit was Rs.201 in which medications accounted for less than 10% of the total cost. Grover et al.[113] found that the total annual cost of care of schizophrenia amounted to Rs.13687.38, which was similar to cost of treatment of diabetes mellitus. Money spent by patients on buying drugs constituted about 18% of the total costs. A study from Chennai showed that despite the cost of blood tests, the total cost of treatment with clozapine came down by nearly 25% compared to the cost before clozapine was started.[114] In another study, Despande[115] reported that the cost of medication to the hospital which provided free medications to subjects with schizophrenia was Rs.288-less than the cost of medications for bipolar disorders.
Research on Tolerability and Side Effects of Antipsychotic [Table 9]
Besides the efficacy or usefulness studies, some studies have specifically
evaluated the side effects and tolerability issues with antipsychotics.[116- 136] In one of the earliest studies, Sarada Menon and Ramachandran[116] reported side effects of subjects who participated in two of their drug trials and had received either trifluperazine or trifluperidol. Other studies have evaluated the rates of skin pigmentation with phenothiazines,[117] rise in prolactin levels with chlorpromazine and trifluperazine[119] and changes in serum electrolytes.[120] Studies have reported prevalence rate of akathesia (25-28%), tardive dyskinesia (5-25.5%) and dystonia (17%) in subjects receiving typical antipsychotic. [118,121-123] Studies have also evaluated the incidence of neuroleptic malignant syndrome[124,134] and extrapyramidal side effects with risperidone.[125] Another study by Pandey et al.[136] compared the rate of neuroleptic - induced acute dystonia and reported that there was no difference in vulnerability to develop dystonias in subjects with mania or schizophrenia. With recent interest in weight gain and metabolic syndrome, some of the studies have shown that patients receiving atypical antipsychotics (Olanzapine or risperidone) gain more weight compared to haloperidol and treatment with antipsychotic leads to disturbance in metabolic syndrome parameters[131-133] whereas others suggest contrary findings.[129,130] Studies have also shown that use of typical antipsychotic leads to higher rates of sexual dysfunction[128] and among the atypical antipsychotic sexual desire is more frequently impaired in subjects on risperidone and erectile dysfunction is more prevalent in subjects on olanzapine.[135]
CONCLUSION AND FUTURE DIRECTIONS
Reasonably good amount of data on the efficacy of antipsychotics in schizophrenia is available from India. In addition, studies also suggest usefulness of antipsychotics in mania, acute and transient psychosis, delusional disorders and agitation and violence. Older studies also suggest that typical antipsychotics have usefulness in anxiety states. Many of the recent studies followed double blind randomized controlled design and had a reasonable sample size. Further, many studies have been carried out at multiple sites throughout the country. To some extent, data is also available with regards to the tolerability of antipsychotics and it shows that extrapyramidal symptoms and NMS are more common with typical antipsychotics and weight gain is more common with antipsychotics like olanzapine and risperidone.
However, the major limitation of the research is that there are not many studies on the treatment of schizophrenia in elderly, in subjects with comorbid physical illnesses and in cases with comorbid substance abuse. Data on long term efficacy of antipsychotics is also meager. There is still a need to conduct long term comparative multicentric studies to evaluate the efficacy, effectiveness, tolerability and side effects of antipsychotics.
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Ajit Avasthi Munish Aggarwal Sandeep Grover Departments of Psychiatry Postgraduate Institute of Medical Education and Research, Chandigarh.
Mohd Khalid Rasheed Khan Pharmacology, Shadan Institute of Medical Sciences, Hyderabad, India 54 Research on antidepressants in India
Ajit Avasthi, Sandeep Grover, Munish Aggarwal
ABSTRACT
Data suggests that antidepressants are useful in the management of depressive disorders, anxiety disorders, sexual dysfunction, eating disorders, impulse control disorders, enuresis, aggression and some personality disorders. Research focusing on the usefulness of antidepressants in India has more or less followed the trends seen in the West. Most of the studies conducted in India have evaluated various antidepressants in depression. In this article, we review studies conducted in India on various antidepressants. The data suggests that antidepressants have been evaluated mainly in the acute phase treatment and rare studies have evaluated the efficacy in continuation phase treatment.
Key words: Antidepressants, research, India
INTRODUCTION
Antidepressants as a class of drugs are used primarily in the management of depressive disorders and anxiety disorders. However, this class of drugs is also used for the management of sexual dysfunction, eating disorders, impulse control disorders, enuresis, aggression and some personality disorders.
Over the years many classes of antidepressants have become available in India, some of which have stood the test of time and are still in use and some, which are no more marketed or are no more a favorite of clinicians. The research focusing the usefulness of antidepressants in India has more or less followed the trends in the west; however, some of the antidepressants drugs which have been marketed have not been evaluated as thoroughly as others.
Most of the studies done in India have evaluated various antidepressants in depression. There are very few studies which have evaluated antidepressants in conditions other than depressive disorders. In this article, we review studies done in India on various antidepressants. The review shall focus on the research published in Indian Journal of Psychiatry and studies reported in PubMed indexed journals on efficacy, effectiveness, usefulness and tolerability issues of antidepressants in human subjects.
Efficacy/effectiveness in Depression
The trials done to evaluate the efficacy of antidepressants can be divided into studies evaluating an antidepressant (no comparator studies), efficacy of an antidepressant with placebo as a comparator, comparing efficacy of 2 active drugs and those evaluating the efficacy of antidepressants with other modalities of treatment like electro-convulsive therapy or psychological treatment.
Non Comparative Studies
A total of 18 open trials without a comparator group have been conducted to evaluate the efficacy of various antidepressants [Table 1].[1-18] Studies done in the 1960s evaluated the efficacy of tricyclic antidepressants. Later studies have evaluated the efficacy of nitroxazepine, centpropazine, amineptine, tianeptine, sertraline and milnacipran. Studies done prior to 1990s have not used any standardized rating scales, most of these also did not mention the diagnostic criteria used for the diagnosis. These studies included subjects diagnosed with various subtypes like reactive depression, endogenous depression, psychoneurotic depression, melancholic depression etc. However, the studies done after 1990s have recruited subjects diagnosed on the basis of DSM or ICD-10 RDC criteria and used standardized rating scales to evaluate the efficacy or effectiveness. The sample sizes of the studies have varied a lot, most of the earlier studies included less than 50 subjects; however, some of the recent studies have included more than 300 subjects. Most of these trials have evaluated the outcome after six weeks. All these trials have shown that various tricyclic antidepressants, nitroxazepine, centpropazine, amineptine, tianeptine, sertraline, escitalopram and milnacipran are efficacious in treatment of depression. The trial which evaluated the efficacy of sertraline also showed that treatment of depression with sertraline leads to reduction in cardiac events post myocardial infarction.[13] A recently published trial, which evaluated the efficacy of milnacipran, included subjects who had suffered from stroke.[18] It is also one of the few trials which have included subjects more than 65 years of age. The trial done by Margoob et al.[17] in addition to the efficacy of escitalopram, have also shown that gene polymorphism plays an important
role in the treatment response to various antidepressants.
Placebo-Controlled Trials
Six placebo controlled trials have evaluated the efficacy of tricyclic antidepressants in depression [Table 2].[19-24] Four of these trials have been double blind controlled trials,[19-22] one recruited subjects by consecutive sampling,[23] and one followed cross over design.[24] The duration of these trials has varied from four to eight weeks and these have included 16 to 96 subjects. Of the five trials, one evaluated the efficacy of imipramine in depressive symptoms in schizophrenia[24] and another included subjects with endogenous depression only. [23] Five of these trials showed that amitriptyline, imipramine, protriptyline and trimipramine are better than placebo in the management of depression;[19-23] however, the trial which evaluated the efficacy of imipramine for depressive symptoms in schizophrenia showed negative findings.[24]
Active Comparator Group Drug Trials of Efficacy
There have been 18 trials which have compared two antidepressants.[25-41] One trial compared amitriptyline with amitriptyline and trifluperazine combination[42] and one trial compared amineptine vs. amineptine with benzodiazepine.[43] In another trial nortriptyline was compared with nortriptyline plus fluphenazine [Table 3].[44] The duration of these trials have varied from 10 days to five months; however, most of these have been of four to six weeks duration. Sample size has also varied considerably ranging from 20 to 425 and only four trials have included 100 or more subjects. In terms of study design, 10 trials have followed double blind controlled design; five of these also followed adequate randomization. One trial followed single blind randomized control design and another three trials were open randomized controlled trials. Earlier trials used mixed group of depressive subjects, whereas, recent trials have included subjects with major depressive disorder only. All the trials have used standard doses of antidepressants.
Of the 21 trials, 18 have assessed the outcome of depression at the end of trial on Hamilton depression rating scale. Findings from these trials suggest that imipramine is superior to Nialmide,[25] phenelzine,[25] Go 2998,[24] Go 2330[26] and moclobemide[37] in the treatment of depression. Antidepressants like noveril,[27] iprindole,[28] trimipramine,[29] dothiepin[31] and centpropazine[34] have efficacy similar to imipramine. Imipramine has been found to be inferior to sintamil.[30] The study which evaluated amitriptyline and trifluperazine combination showed that it was no better than amitriptyline alone.[42] Interestingly, the study which used fluphenazine found it to be as efficacious as nortriptyline. [44] Nitroxazepine
has been shown to be better than doxepin in treatment of depression.[32] The amineptine trial, didn't present data with regard to comparison in efficacy between the various groups of medications.[43] The studies which have compared various selective serotonin reuptake inhibitors have shown that these are equally effective, except for one which showed that citalopram was better than sertraline.[41] The only trial done on mirtazapine suggests that it is better than amitriptyline.[35] Studies have also shown that citalopram[38] and tianeptine[11] are as efficacious as amitriptyline. The trial by Badyal et al.[39] suggests that duloxetine is as efficacious as venlafaxine in the treatment of major depression. One of the recent multicentric trials have shown that escitalopram is superior to investigational drug LY2216684.[41]
Active Comparator Group (non-pharmacological treatment/electroconvulsive therapy) Trials of Efficacy/Effectiveness.
One study has compared the usefulness of antidepressants with respect to non pharmacological treatment[45] and two studies have compared antidepressants with electroconvulsive therapy for treatment of depression. [46,47] Another study compared antidepressants with both electroconvulsive therapy (ECT) and non-pharmacological treatment [Table 4].[48]
One of these studies has shown that pharmacotherapy is more effective and more economical than non-pharmacological treatment.[45] However, one study showed no difference between ECT, antidepressant and Sudarshan kriya in the management of depression over the period of three weeks. [48] The studies which compared ECT with imipramine didn't find any difference in efficacy between the two;[46,47] however, Gangadhar et al. reported quicker response with ECT compared to imipramine.
Dosing Studies of Antidepressants [Table 5]
Seven trials have evaluated the different dosing schedules for treatment of depression.[49-56] These studies suggest that parenteral imipramine is better than oral imipramine and possibly the onset of action is also earlier.[49] Studies have evaluated single dosing versus multiple dosing have shown no difference in efficacy[50-52,54,55] except for one study, which showed that single dose nitroxazepine was better than divided doses.[53]
Prescription Patterns of Antidepressants in Depression
Chakrabarti and Kulhara[57,58] evaluated the antidepressant prescription pattern in a tertiary care hospital for management of depression during acute and continuation phase. For the evaluation of prescription pattern during the acute phase, case notes of 108 cases fulfilling the ICD-10 criteria of
depression or recurrent depression (F32 and F33) were examined. Imipramine was the most commonly prescribed antidepressants followed by Fluoxetine. The authors also observed that pharmacotherapy was often deficient in several areas such as, starting doses, rate of increase in dose, maximum doses used, dose titrations, duration of treatment, change of drugs, recording of side-effects and compliance etc. Results regarding norms for adequate doses and periods of treatment before switching drugs, for the kind of subjects included in this study, were unclear. Regarding the continuation phase treatment, the authors observed that it was deficient in about a third (n 5 24; 34 %) of the cases, on either of the two parameters i.e., dose of drugs or duration of treatment and the outcome was poorer in those treated inadequately.
Efficacy/effectiveness in Disorders Other Than Depression Obsessive compulsive disorder/symptoms [Table 6]
One double blind controlled trial has evaluated the efficacy of clomipramine in the treatment of OCD and showed that clomipramine was superior to placebo in the management of OCD.[59] This study also showed that male subjects showed better response than female subjects. Another study evaluated the efficacy of clomipramine in late onset OCD with comorbid Parkinsonism and showed that clomipramine can be used in elderly subjects and in the presence of Parkinsonism.[60] A small open label study evaluated the usefulness of neuroleptic and fluoxetine combination for treatment of obsessive compulsive (OC) symptoms occurring during the course of schizophrenia and showed that addition of fluoxetine leads to significant improvement in OC symptoms.[61]
Insomnia [Table 6]
One study evaluated the efficacy of antidepressants in insomnia and showed that trimipramine was similar to nitrazepam for treatment of insomnia, especially in the presence of anxiety and depression; however, it had poor tolerability as compared to nitrazepam.[62]
Generalized Anxiety Disorder [Table 6]
One trial included subjects with generalized anxiety disorder, mixed anxiety depression and dysthymia and showed that imipramine was as effective as diazepam for anxiety symptoms and better than diazepam for the depressive symptoms.[63]
Depressive Symptoms in Schizophrenia [Table 6]
One trial used imipramine in combination of chlorpromazine and compared it with chlorpromazine alone in the treatment of depressive symptoms in schizophrenia and didn't find any benefit of adding imipramine to chlorpromazine in the treatment of treatment of depressive symptoms in schizophrenia.[64]
Common Mental Disorders [Table 6]
Two studies have also studied the usefulness of antidepressants in common mental disorders. One study showed that treatment completion rates were higher with fluoxetine than imipramine.[65] The trial by Patel et al.[66] included subjects with common mental disorders and evaluated the outcome at one year. It can be considered the longest study which has evaluated the effectiveness of antidepressant in Indian subjects.
Sexual Dysfunction [Table 6]
Various sexual side-effects of antidepressants have been utilized for the management of sexual dysfunction. In a recently published open trial Dhikav et al.[67] compared fluoxetine with yoga for the management of premature ejaculation. The study included 68 subjects, of whom 38 were in the yoga group and 30 subjects in the fluoxetine group. All 38 subjects (25-65.7% 5 good, 13-34.2% 5 fair) of yoga group and 25 out of 30 of the fluoxetine group (82.3%) had statistically significant improvement in premature ejaculation and the difference between the two groups was statistically significant too. In an open clinical study, Prusty and Rath (2000)[68] found clomipramine effective in nocturnal emission. In another open trial, Prusty et al. (2003)[69] found clomipramine 5 mg along with Sildenafil 50 mg was successful in preventing premature ejaculation of 18 men who had erectile dysfunction also.
Childhood Onset Disorders [Table 7]
Two studies have evaluated imipramine for management of enuresis in children.[70,71] In one of these trials,[71] in addition to enuresis, children had other behavioral abnormalities too. These studies have shown that imipramine is useful for management of enuresis and also for behavioral problems like obstinacy and temper tantrums. It was further seen that compared to subjects with mental retardation, the response to imipramine was better in children with average intelligence.
Usefulness in other conditions [Table 8]
Besides the above studies, case series and case reports have also shown usefulness of antidepressants in the management of trichotillomania with trichobezoar,[72] Atypical bulimia Nervosa,[73] Skin Picking,[74] Persistent developmental stuttering,[75] primary hypersomnia,[76] cognitive functioning in depression,[77] proctalgia fugax with dysthymia,[78] palmar- plantar hyperhidrosis,[79] severe resistant depression[80] etc. One open label study also evaluated the usefulness of sertraline in chronic tension type headache and showed that sertraline leads to significant reduction in mean analgesic intake per week, but there is no difference in reduction of headache index and frequency of headache.[81]
Tolerability of Antidepressants
As is evident from Table 1 to 6, tricyclic antidepressants are poorly tolerated compared to the newer antidepressants. Additionally, there are multiple case reports implicating various antidepressants for induction of hypomania/mania,[87-96] hyponatremia/Syndrome of inappropriate antidiuretic hormone secretion (SIADH),[97-99] extrapyramidal symptoms,[100] acute colonic (pseudo) obstruction (Ogilvie syndrome),[101,102] psychosis,[103] hypertension,[104] vascular headache,[105] torsades de pointes,[106] alopecia,[107] cardiogenic shock,[108] seizures,[109,110] galactorrhoea,[111] mania on withdrawal of antidepressants,[112] upper gastrointestinal bleeding,[113] bleeding gums,[114] serotonin syndrome[116,117] etc [Table 9].
Antidepressant Withdrawal/Dependence
One case report presented tricyclic withdrawal syndrome with amitriptyline 300 mg/day[121] and another was described by Jhirwal and Chakrabarti[122] with Venlafaxine. Dependence syndrome has been described with dothiepin 450 mg/day.[123]
Safety in Overdose
In a case report, Gupta et al.[115] described a patient who could tolerate paroxetine 560 mg/day.
Conclusion and Future Directions
Many studies have evaluated the efficacy of antidepressants in depression and have shown that most of the currently marketed antidepressants are useful. In addition, studies also suggest usefulness of antidepressants in generalized anxiety disorder, dysthymia and common mental disorders. Many of the recent studies have been of good design and have followed double blind randomized controlled design and had reasonable sample size. Further, several studies have been carried out at multiple sites throughout the country. The available data also suggest that antidepressants are more cost- effective than other modalities of treatment for depression.
In addition, there is some evidence to suggest the usefulness of clomipramine in OCD and that of fluoxetine in management of OC symptoms in schizophrenia. However, some major limitations of the research have been that almost all the data available in relation to treatment of depression pertains to acute phase treatment and rarely studies have evaluated the continuation phase treatment. There is also lack of data with regard to the efficacy and effectiveness in the maintenance phase treatment. Surprisingly, no study has evaluated the efficacy/effectiveness of SSRIs in the management of OCD.
There is a need to conduct studies to evaluate the usefulness of antidepressants in the management of panic disorder and depression in medically ill subjects. Studies are also required to evaluate the efficacy of SSRIs in the management of OCD, and to study the usefulness of polypharmacy in the management of depression and other disorders. Studies are few and sparse and there is a need for multi-centric studies in such a vast country. REFERENCES
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Ajit Avasthi Sandeep Grover Munish Aggarwal Department of Psychiatry Postgraduate Institute of Medical Education and Research, Chandigarh, India 55 Research on mood stabilizers in India
Ajit Avasthi, Sandeep Grover, Munish Aggarwal
ABSTRACT
Mood stabilizers have revolutionized the treatment of bipolar affective disorders. We review data originating from India in the form of efficacy, effectiveness, usefulness, safety and tolerability of mood stabilizers. Data is mainly available for the usefulness and side-effects of lithium. A few studies in recent times have evaluated the usefulness of carbamazepine, valproate, atypical antipsychotics and verapamil. Occasional studies have compared two mood stabilizers. Data for long term efficacy and safety is conspicuously lacking.
Key words: India, Mood stabilizers, Research
INTRODUCTION
Psychopharmacology has revolutionized the understanding and treatment of major mental disorders. With the help of psychopharmacological agents, not only is the neurobiology of various psychiatric disorders being understood, but effective treatments have improved relapse rates, symptom free period, significantly improved the quality of life of patients and have reduced the burden experienced by patients and their families.
Prior to lithium, typical antipsychotics and electroconvulsive therapy was used for management of bipolar disorders. However, over the years many drugs have been evaluated as mood stabilizers and have been shown to be efficacious, although the definition of a mood stabilizer is not yet settled.
Psychopharmacological research in India regarding mood stabilizers has lagged behind the data from the West. However, there has been a shift of research from mere case series to attempts at multicentric double blind controlled trials. In this review, we would review data on mood stabilizers originating from India on various mood stabilizers. The review shall focus on the research published in Indian Journal of Psychiatry and studies reported in PubMed indexed journals. MOOD STABILIZERS
Amongst various mood stabilizers now available in India, lithium has been the most researched of all. There are a few studies on other mood stabilizers such as carbamazepine and sodium valproate.
Lithium
After its introduction in India in the late 1960s, lithium aroused a lot of research interest in the 1970s and 80s, with most of the research revolving around open trials to see its usefulness in various disorders (mainly mood disorders) and its side-effect.
Effectiveness in mood disorders
The mood stabilizing property of lithium has led Indian researchers to see its effects in affective disorders. In their earliest work on role of lithium on mood disorders, Dube et al.[1] in an uncontrolled trial of lithium in 20 hypomanic patients found that 95% patients showed significant improvement. There have been other studies to see the effectiveness of lithium in mood disorders.[2-8] Most of these studies have been open label, non-controlled, with assessment period varying from one month to 10 years and have sparingly used assessment scales. Lithium has been found useful in treating acute episodes, reducing number of episodes, duration and intensity of episodes, behavior and suicidal ideation.[3,5,6,8] Studies have also looked for the socio-clinical correlates which influence the effectiveness of lithium. It has been shown that effectiveness of lithium is influenced by age and sex[4] and good response is predicted by lesser number of episodes prior to initiation of lithium therapy, long duration of illness,[4] and presence of family history of affective disorder.[2,5] Patients with rapid cycling mood disorder and unipolar disorder were seen to respond poorly.[2,4,9] Studies have also evaluated the utility of single dose vs. divided dose of lithium in prophylaxis of mood disorders. One study concluded that single daily dose was more useful in reducing number of affective episodes than divided doses[10] whereas another retrospective case review concluded that there was no difference in the efficacy and adverse effect in patients with once daily lithium versus lithium in divided doses.[11] In an effort to find effectiveness of lithium in mood disorders in children, Khandelwal et al.[12] found that lithium in dose of 750-1000 mg/ day (serum lithium of 0.6-1.2 mEq/L) was useful in acute control and chronic prophylaxis. Despite a good number of studies, most of these studies are limited in terms of small number of patients, short duration of follow up and neglect of important variables such as quality of life etc. Only one study from PGIMER, Chandigarh, evaluated the quality of life (QOL) of subjects with bipolar disorder stabilized on lithium prophylaxis using World Health Organization (WHO) Quality of Life-Bref (WHOQOL-BREF) and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) along with factors that contribute or influence QOL and compared the same with schizophrenia and healthy control subjects. It was found that compared to the schizophrenia group, the bipolar group had significantly better QOL in all the domains of Q-LES-Q and the domains of general well-being, physical health and psychological health of the WHOQOL-Bref. The bipolar group had similar QOL scores in all other domains and higher scores in leisure time activity domain of Q-LES-Q, in comparison to the healthy group. These findings suggest that lithium contributes significantly to improvement in QOL in subjects with bipolar disorders.[13]
With regard to early onset bipolar disorder a retrospective chart review found that lithium was the most commonly used mood stabilizer, followed by valproate. However, during the follow-up period of three to 56 months it was seen that 28% of subjects relapsed despite being on apparently adequate doses of lithium.[14]
With regard to organic mania, a recent case report by Loganathan et al.[15] reported usefulness of lithium in treatment of mania in subjects with Wilson's disease.
Predictor of response to lithium
Sampath et al. (1980)[16] determined RBC/plasma lithium ratio in 35 manic patients who were on lithium for three months and determined its relation to response. It was found that ratio was higher in responders than non- responders. Similarly, Pradhan and Channabasavanna[17] examined the relation of intracellular Na1, K1, Li1 to extra cellular concentration of these ions in a group of 22 patients of bipolar affective disorder who were divided into responders and non-responders. No significant difference between two groups was found as regards to these values.
Useful in schizophrenia and other disorders
In a double blind placebo controlled cross over trial between lithium and chlorpromazine lasting for four weeks, Dube and Sethi[18] reported that lithium was not found to be superior to chlorpromazine in severity and global improvement but selective effectiveness of lithium was seen in controlling hyperactivity, excitement, hostility and emotional withdrawal symptoms in schizophrenia and based on this the authors recommended use of lithium as adjuvant for specific symptoms. However, one study showed that lithium was ineffective in chronic hypochondriacal and schizoaffective disorders.[19] Studies have also showed that lithium is useful in management of aggression in patients of various diagnostic categories who were non-responsive to antipsychotics, electroconvulsive therapy, antiepileptics and sedatives. Authors recommended use of lithium in dose of 500- 750 mg/day (Serum lithium 0.75-1.2 mEq/L) in patients with unspecified aggression.[20] Lithium has also been used successfully for treatment of Kleine-Levin Syndrome,[21] Ganser syndrome[22] and Neuroacanthocytosis.[23]
Research on serum lithium levels and related issues
Attempts have been made to estimate saliva levels and see their correlation with serum lithium levels with conflicting results. Prakash et al.[24] investigated equal number of serum and saliva samples for lithium level estimation and reported high correlation between the two. On the other hand, in a methodologically and statistically strong study undertaken by Natraj and Bhat,[25] lithium levels in saliva were reported to be an unreliable indicator of serum lithium levels. Pandey et al.[26] compared the serum lithium levels with use of single equivalent dose of sustained release lithium preparation and plain lithium preparation in 18 healthy volunteers. Serum lithium levels were estimated at four-hourly intervals. With plain lithium preparation majority of patients achieved serum lithium within therapeutic range but only half of patients with sustained release preparations achieved the therapeutic range. Further, the standard deviations of levels of lithium were more with sustained release suggesting high fluctuations in serum levels. The study is important in the context that more and more practitioners tend to use sustained release preparation, which might lead on to fluctuation in serum level which practitioners may not be aware of. Based on observation of widely fluctuating serum levels with respect to time and quality control, Kuruvilla et al.[27] observed that it was essential to run a quality control sample with each test sample as an independent check prior to estimation. It was also pointed out that similar equivalent result can be obtained whether blood sample is analyzed within six hours or 5-6 days. Similar findings were reported by Khandelwal et al.[28] who based on sample analysis of two groups of patients (in one sample stored at room temperature for 6 days and other stored at 24°C for 8 days) concluded that lithium levels remained same irrespective of time of analysis. This observation may be important keeping in view limited number of laboratories in India and time spent on transporting samples. Kuruvilla and Shaji[29] found that 24 hours blood levels of lithium after test dose were not reliable enough to predict therapeutic serum lithium levels. In a recent study significantly high variability of lithium levels in different months of the year was reported and authors suggested that frequent serum level monitoring and oral lithium dose adjustment needs to be done to prevent situations of toxicity and lack of efficacy. [30] In a case series (N 5 3), Tripathi et al. [31] reported that when compared to standard normal diet bioavailability of lithium is reduced by high fat food.
Side-effects of lithium
Research on side-effects of lithium has been focused on general side-effects and specific side-effects on various systems.
General
Venkoba Rao et al.[32] examined side-effects to lithium (dose 750-1000 mg/day, serum lithium between 0.6-1.2 m Eq/L) in patients of mood disorders who were receiving lithium for three months and reported that nearly 81% patients had at least one side-effect with 14% having more than one side- effect. Common side-effects reported were tremors, polyuria, memory deficits, excessive salivation and gastrointestinal side-effects. In another comparative study which evaluated the side-effects of lithium, carbamazepine and haloperidol in acute mania, Trivedi et al.[33] reported that though total side-effects were not much different between the three groups, the rate of amelioration was best for lithium and least for haloperidol, indicating lithium to be better tolerated.
Cognitive functions
One study compared the cognitive function of 34 bipolar patients on lithium (serum lithium between 0.6-1.2 mEq/L) with 30 matched controls. There was no difference on cognitive testing as measured by Bhatia Battery test, PGI memory scale and Bender Gestalt test. However, on self assessment of cognitive functions, patients experienced feeling of subjective cognitive impairment.[34] Researchers have also used animal models to study the effects of lithium on memory functions. In an experimental design on 30 albino rats, Sethi et al.[35] performed brightness discrimination and observed reaction time, positive response during relearning and relearning index and found that mice exposed to chronic administration of lithium had reduction in size of memory trace laid during previous learning. Further, lithium interfered with ability to perform learned behavior and long term memory.
Neurological
Residual neurological side-effects after lithium toxicity in the form of dysarthria, nystagmus and generalized cerebellar damage have been reported.[36-40] Andrade et al.[41] also reported that lithium neurotoxicity can occur with therapeutic lithium levels. In another retrospective chart review of patients with lithium toxicity, Kumar et al.[42] reported that toxicity even occurs with therapeutic lithium levels and is commonly seen in subjects receiving antipsychotics along with lithium and cerebellar symptoms are the most common presentation, which occur at significantly lesser serum levels. Chakrabarti and Chand[43] reported a case of tardive dystonia with lithium.
Renal
Five controlled studies have examined renal side-effects of lithium in humans.[32,44-47] In comparison to age and gender matched controls, it has been shown that patients on lithium for variable duration have been found to have anti- diuretic hormone resistant concentration deficit resulting in polyuria, impaired creatinine clearances, low renal tubular H1 excretion, normal glomerular filtration rate (GFR) and renal tubular acidification. It has also been shown that serum lithium levels correlate positively with daily urine volume and negatively with urine specific gravity. Studies have also shown that there is no relationship between total amount of lithium consumed or duration of treatment with renal impairments.[32,44,46] A recent study showed that there was no difference in GFR between affective disorders patients on lithium and normal controls.[48] Another study reported lack of deterioration in renal functions of subjects on lithium for 1 year.[49] In one study renal biopsy of patients on lithium showed non-specific abnormalities of glomerular hypercellularity, cloudy swelling of tubular epithelium and interstitial fibrosis. However, these findings had no correlation with renal functioning and duration of lithium treatment.[45] Despite the above conclusive findings, most of the studies mentioned have a small sample size, are cross sectional and poorly controlled.
Thyroid functions
Despite well-documented adverse effects of lithium on thyroid functions and good quality research from West, there has been little enthusiasm to study thyroid functions in Indian subjects. In an uncontrolled study which included 40 patients with bipolar disorder on prophylactic lithium with serum lithium of 0.83 (SD 0.20 mEq/L), Kuruvilla et al.[50] assessed thyroid functions at baseline and after two years and didn't find any significant difference in total T4, free thyroid index or TSH. Srivastava et al.[51] compared thyroid hormone level of 30 patients with bipolar disorder on lithium (6-24 months) and with healthy controls and found an increase in the level of TSH (more than the normal range) in 20% of subjects, normal T3 levels and decreased T4 levels in 13% of subjects with bipolar disorder. The authors noted that high dose and high serum lithium levels increase the possibility of reduction of thyroid function status. In a case report Jayesh[52] reported clinical hypothyroidism in a male patient on lithium therapy for 12 months, which persisted despite discontinuation of lithium. In a study from PGIMER, Chandigarh, Deodhar et al. [53] compared the thyroid functions of 24 healthy controls and 132 affective disorder subjects. They found that lithium treatment induced sub-clinical hypothyroidism in 51/132 (39%) of patients and the levels of T4 declined significantly (P , 0.05) with lithium treatment ranging from 61 to 240 months as compared to the corresponding values in the control group.
Cardiovascular
Venkoba Rao and Hariharsubramaniam[54] examined ECG changes in patients on lithium for 1-43 months (dose 900-1500 mg/day, serum lithium 0.8-1.2 mEq/L) and reported slow sinus rhythm, prolongation of intraventricular conduction and interference with repolarization. Longer duration of therapy and age were found to influence the ECG changes. Based on their finding the authors recommended occasional ECG monitoring in elderly patients on long-term lithium therapy. Kurpad et al.[55] reported a case of ventricular ectopic in a patient on lithium. In a recent case report, Praharaj et al.[56] reported bradycardia with lithium at therapeutic doses in a case of bipolar disorder with bilateral thenar hypoplasia, which resembles a milder variety of Holt-Oram syndrome.
Electrolyte Disturbance
Srinivasan et al.[57] assessed Mg12, Ca12 levels in 17 patients of affective disorder, on lithium and followed them prospectively and observed increase of total serum Mg12, which was more so in patients who relapsed and the authors pointed at deficiency of Mg12 at cellular level as a probable cause of episodes.
Tilak effect
Parvathi Devi and Rao[58] labeled the stimulatory action of lithium on pineal gland as "Tilak effect." Same groups of authors researched effects of lithium on adrenal cortex in an experimental group of mice.[59]
Pregnancy
In a case report Grover and Gupta[60] reported congenital malformation in the form of anencephaly with use of lithium in first trimester. In another case report, still birth was reported by Khandelwal et al.[61] with the use of lithium during pregnancy.
Psychiatric Side-effects In a case report, abrupt withdrawal of lithium in a patient with recurrent depressive disorder led to development of hypomania.[62]
Carbamazepine
Usefulness
In contrast to lithium there has been little research on use of carbamazepine in psychiatric disorders from India. In a controlled trial, Sethi et al.[63] recruited 16 patients with affective disorder (unipolar or bipolar); eight were put on carbamazepine (1000-1600 mg/day) and another eight on either chlorpromazine or imipramine. Patients in the depressive phase were given carbamazepine or imipramine and patients in manic phase were given either carbamazepine or chlorpromazine. Six out of eight patients on carbamazepine showed moderate to marked improvement in symptoms after 4 weeks of treatment. One patient showed 50% improvement and another patient on carbamazepine discontinued the therapy due to marked side- effects. Desai et al.[64] reported a case of mania treated with combination of lithium and carbamazepine.
Based on the kindling hypothesis, Das et al.[65] divided the subjects of bipolar disorders as kindlers (as patients with 3 or more affective episodes in #1 year) and non-kindlers (as patients with at least 3 episodes in the past with inter episodic period of more than 1 year) and evaluated the response to carbamazepine (mean dose- 718 6 109 mg/day) over a period of six months and reported no significant difference between the two groups based on sex, past history of substance intake, type of mood (irritable versus elated), number of relapses during the follow-up and improvement on carbamazepine. Sadanandan and Anand[66] reported three patients with epilepsy and interictal hyper-religiosity who responded well to become asymptomatic with carbamazepine. In a case report, Patkar et al.[67] reported that carbamazepine may be effective in prepubertal lithium refractory rapid cycling subjects.
Side-effects
A case series suggested that carbamazepine (600 mg/day) can lead to worsening of psychotic symptoms in toxic range.[68]
Valproate
Usefulness
Among the three mood stabilizers, valproate has been used most recently for treatment of mood disorders. Some of the recent studies have compared the efficacy/effectiveness of valproate with other mood stabilizers.[69-74] A few case series have shown effectiveness of intravenous valproate in management of acute mania without any serious adverse effects.[75,76]
Usefulness in other conditions
Chadda et al.[77] evaluated the usefulness of sodium valproate (1200 mg/day) for four weeks in tardive-dyskinesia and showed statistically significant improvement after two weeks which persisted at four-week assessment. In a case report, valproate has also been found to be useful in management of menstrual psychosis.[78]
Side-effects
In a recent case series, Pradeep[79] presented three cases of delirium with hyperammonemia in subjects receiving valproate monotherapy.
Atypical Antipsychotics
In a three-week randomized, double-blind trial, Khanna et al.[80] included subjects of bipolar I disorder with mania or mixed episode as per DSM-IV diagnosis, who were more than 18 years old, and had a baseline Young Mania Rating Score of more than 20. The subjects were admitted to hospital and then randomly assigned in equal numbers to receive placebo or 1-6 mg of risperidone. Randomization was stratified by the presence or absence of psychotic features at baseline, manic or mixed episode and by treatment centre. Risperidone was received by 146 patients and placebo by 144. Their mean baseline YMRS score was 37.2. Treatment efficacy was determined primarily by the change from baseline to end-point in mean total scores on the Young Mania Rating Scores. At the end of three weeks, significantly greater improvement were observed with risperidone than with placebo at weeks 1 and 2 and at end-point (total YMRS: P , 0.01). The mean YMRS score of 37.2 at baseline reduced to 14.5 at the end of the trial in the risperidone group and this was significantly better than the placebo group. Extrapyramidal side-effects were reported by 35% of subjects in the risperidone group (compared to 6% in the placebo group) and these were the most frequently reported adverse events in the risperidone group. Another side-effect which was reported by more than 10% of subjects was insomnia; however there was no difference between the two groups on the incidence of the same.
Studies comparing various mood stabilizers
Few studies have compared the efficacy/effectiveness of various mood stabilizers in affective disorders. In a randomized controlled trial of four weeks duration, Prakash and Bharath[69] compared the efficacy of valproate (N 5 10; 600-1200 mg/day) and lithium (N 5 11; 900- 1500 mg/day) in the treatment of acute mania and found that valproate was as efficacious as lithium in controlling the acute manic episode. Of the 10 patients randomized to valproate, 80% responded to 600 to 1200 mg of sodium valproate within two to three weeks indicated by a 50% reduction in total scores in Beigel's Mania Rating Scale (BMRS). Subjects in both the groups required equal doses of adjuvant benzodiazepines. Side-effects of valproate were similar to lithium except that 1 patient in valproate group developed hepatitis. Another study compared antimanic efficacy of carbamazepine (started at 20 mg/kg body weight per day and titrated as per requirement) with valproic acid (started at 20 mg/kg body weight per day and titrated as per requirement) and reported that valproic acid was more efficacious than carbamazepine (CBZ).[70] Of the valproic acid treated patients, 73% showed a favorable clinical response while 53% of the patients on carbamazepine responded favourably. Using the intent-to-treat analysis, it was seen that valproic acid led to significant reduction in YMRS total scores after week 1 while the carbamazepine group showed significant reduction after week 2.
In the primary efficacy analysis, valproate group experienced significantly greater mean improvement in Young Mania Rating Scale total score than the carbamazepine group. In the CBZ group, significantly more patients required rescue medication during the week 2 and the requirement was quantitatively more as compared to the valproic acid group. [70] In a recent 12 week, randomized, double-blind pilot study involving 60 subjects diagnosed with acute mania (DSM-IV), Kakkar et al.[71] compared the efficacy and safety of oxcarbazepine (1,000-2,400 mg/day) and divalproex (750-2,000 mg/day) in the treatment of acute mania. In both the groups, the authors found comparable improvement in mean YMRS scores including the mean total scores as well as percentage fall from baseline. There were no significant differences between treatments in the rates of symptomatic mania remission (90% in divalproex and 80% in oxcarbazepine group) and subsequent relapse. Median time taken to symptomatic remission was 56 days in divalproex group while it was 70 days in the oxcarbazepine group (P 5 0.123).
A significantly greater number of patients in divalproex group experienced one or more adverse drug events as compared to patients in the oxcarbazepine group (66.7% versus 30%, P , 0.01). In a 1 week parallel group randomized comparative prospective study trial, Solanki et al.[72] evaluated the effectiveness of injectable sodium valproate (1500-2000 mg/day given in divided doses by IV infusion with 500 cc of 5% distilled water) in controlling the acute mania (N 5 60) and showed that there was substantial improvement in YMRS scores and valproate was significantly better than risperidone. Of the 30 subjects randomized to valproate, 18 showed more than 50% reduction in Young Mania rating scale (YMRS) scores, six showed minimal improvement (less than 25% reduction in YMRS score), four showed no changes and two patients became worse at the end of the trial (because of psychotic features). No serious adverse effects were seen in any patient on valproate and the adverse effects which were noted were of mild intensity and included marginal (benign) elevation of liver enzymes (SGOT and SGPT) in 24 patients, flatulence in one patient, diarrhea in two patients, vomiting in 3 patients, nausea in 5 patients and thrombophlebitis in one patient. Findings of this study suggest that injectable valproate may be a good option in management of acute mania. Another study compared lithium (N 5 25) and verapamil (N 5 25) in a four-week double-blind randomized controlled trial in the management of acute mania. The subjects were rated on Bech-Raefelson Mania Rating Scale and Young-Mania Rating scale. At the end of four weeks the authors found that lithium and verapamil have equal efficacy.[73]
In a naturalistic follow-up study of four years, of subjects presenting with first episode mania (N 5 51), Khess et al.[74] compared the effectiveness of lithium, carbamazepine, valproate and antipsychotic in preventing the recurrence of symptoms and found that patients receiving lithium had the best outcome with only 30.77% having recurrence compared to 70.65% subjects on other drugs and 100% on no drugs. Patients with family history and poor compliance had greater number of relapses and late age of onset and concurrent use of substance led to greater number of admissions.
Mood Stabilizer polypharmacy
Usefulness
In an open label six-month prospective randomized controlled trial, Gangadhar et al.[81] compared the efficacy of lithium alone (900 mg/day; serum levels of 0.8- 1.2) with lithium (900 mg/day; serum levels of 0.8-1.2) plus carbamazepine (200 mg BD) and reported statistically non-significant trend favoring the combination therapy and suggested that addition of carbamazepine hastens recovery and leads to less frequent use of emergency sedation without any increase in side-effects. The findings of Gangadhar et al.[81] are also supported by a case report in which the authors reported that lithium (1500 mg/ day) along with carbamazepine (600 mg/day) led to marked clinical improvement with sustained recovery in a patient who showed poor response to lithium, neuroleptics and ECT and developed severe extrapyramidal side-effects restricting the use of neuroleptics in high doses.[64] Side-effects due to use of polypharmacy
Various case reports have suggested that use of multiple medications in subjects with affective disorders can lead to side-effects like Steven Johnson syndrome.[82-85] Case reports also suggest development of neuroleptic malignant syndrome in young subjects when lithium is combined with olanzapine[86] or haloperidol and carbamazepine.[87]
CONCLUSION AND FUTURE DIRECTIONS
Most of the literature on mood stabilizers pertains to lithium. Studies have found it to be useful in Indian patients for management of bipolar disorders. In recent times, studies have also compared valproate with lithium and have reported it to be as effective as lithium and more effective than risperidone in management of acute mania. Valproate has also been reported to be better than carbamazepine but equally efficacious to oxcarbazepine in management of acute mania. One double blind randomized controlled trial has also demonstrated risperidone to be better than placebo in the management of acute mania. Studies have also shown that addition of carbamazepine to lithium may be useful in management of acute mania.
However, major limitations of the research have been small sample size and lack of multicentric studies. There are no studies which have evaluated the efficacy or effectiveness of various mood stabilizers in the management of bipolar depression. There is dearth of data with regard to usefulness of various medications for prophylaxis. There is an urgent need to conduct multicentric studies.
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Ajit Avasthi Sandeep Grover Munish Aggarwal Department of Psychiatry Postgraduate Institute of Medical Education and Research, Chandigarh, India 56 Research on electroconvulsive therapy in India: An overview
Bangalore N. Gangadhar, Vivek H. Phutane, Jagadisha Thirthalli
ABSTRACT
The contribution of researchers from India in the field of electroconvulsive therapy (ECT) has been substantial. Over 250 papers have been published by authors from India in the past five decades on this issue; about half of these have appeared in the Indian Journal of Psychiatry. This article summarizes the papers on ECT research that have appeared in the Journal. A bulk of these articles has focused on establishing the efficacy in different disorders. Considerable numbers of papers describe refinement in the ECT procedure, including anesthetic modification, ECT machine and EEG monitoring. Papers on neurobiology of ECT and long-term follow-up of ECT-treated patients form a minority. Despite the decline in the use of ECT across the globe, papers on ECT have only increased in the recent decades in the Journal.
Key words: ECT, Research, Indian
INTRODUCTION
Prologue
In this essay we attempt to follow research publications on Electro Convulsive Therapy (ECT), in the Indian Journal of Psychiatry, across the last five decades. We searched the database of the Indian Journal of Psychiatry for ECT research articles. We excluded reviews, orations, editorials and letters. More ECT publications from researchers in India have appeared in the recent 3 decades in other indexed journals (PubMed). Clearly, there is a need to examine all available ECT publications from Indian researchers to understand the present status. In the IJP alone, nearly 90 publications have appeared in the last five decades. Figure 1 clearly indicates a steady rise in ECT publications appearing in IJP over these decades; the number in the last decade alone equals the number of all publications in the first three decades. A national workshop on ECT towards the end of the third decade (1989) may have given an impetus to ECT research that explains a sharp increase in the number of ECT publications. Two Tilak Venkoba Rao oration awards of the Indian Psychiatric Society were published on ECT.
Early trends [Figure 1]
Dr. DLN Murthy Rao published the first ever article describing the ectonus method ECT stimulation. With the development of ECT stimulus machinery, though, this method of stimulation has now become obsolete. Initial reports documented the positive experience of use of ECT in a series of patients of either schizophrenia or manic depressive psychosis. Though ECT was introduced after its success in schizophrenia, the use of ECT in this diagnostic group has now become less frequent. Depression appears to be the most common diagnosis in ECT patients world over; this is not true of India, though. Similarly, researchers recorded the experience with adverse effects of ECT. The observations too were reassuring; the adverse effects were not alarming. Though most ECT services practiced only unmodified ECT for many decades, attempts at studying the role of modifying ECT with some anesthetic medications were published in the initial decade itself. No doubt, this offered a firm foundation for a change in ECT practice towards modified procedures in the later decades (in fact, two of the authors of this paper have not seen unmodified ECT at all).
Electroconvulsive therapy modification
The current practice includes use of anesthesia and muscle relaxant in modified ECT. Researchers explored different 'anesthetics' that include thiopentone, propanadid, etomidate, althesin and diazepam. Propanadid demonstrated some advantages over the more commonly used thiopentone in terms of faster recovery and blunted cardiovascular changes during ECT. The advantages did not perhaps outweigh the cost benefits and practical problems like anesthetists' experience with propanadid that allowed thiopentone to remain the anesthetic of choice in modified ECT. A survey, conducted early in 1990s, indicates that unmodified ECT was the most prevalent practice in ECT. Muscle relaxation is a serious concern that limits modified ECT practice and calls for a more professional anesthesiologist's attendance. Yet, as early as 1962, Dr. Bagadia used succinylcholine successfully in modified ECT. A method to assess the extent of muscle relaxation-related seizure modification was also developed as a tool for this area of ECT research, though much later (1999).
The relative merits of retaining the unmodified ECT as regards safety compared to the much-advocated modified ECT have been documented. A more recent study supported use of unmodified ECT if enforcing modified procedure discouraged use of ECT itself. This subject attracted comments on the debate of unmodified versus modified ECT.
Efficacy of electroconvulsive therapy
Expectedly, schizophrenia was the first condition tested in comparative trials of ECT. ECT added to the concurrent antipsychotic medication benefitted schizophrenia patients. One observation even noted that ECT conferred 'protection' against the drug-induced Parkinsonism. In the days of clozapine, a drug recommended for drug-resistant schizophrenias, ECT got a renewed interest. The former drug has feared side-effects of seizures. However, concurrent ECT in clozapine treated patients has not pointed to such concerns, though some precaution has been suggested in such combinations. When used as a first-line of treatment, ECT may just be as good as conventional doses of a standard antidepressant drug though the latter contributed to more adverse effects. In contrast to the well acclaimed dramatic effects of ECT in catatonia, one research report found that lorazepam produced nearly comparable anti-catatonic effects. Yet, ECT is perhaps the first preferred alternative therapy in catatonia when lorazepam is unsuccessful.
Predictors of electroconvulsive therapy efficacy
Many observations of predictors for response to ECT in depression, noted in standard ECT text books, have been confirmed in independent studies though with some exceptions. The response to the first ECT pointed to a subsequent response in the course for depression. Cardiovascular responses pointed to the potency of the seizure and hence successfully predict the therapeutic efficacy in depression.
Adverse effects
Ever since the introduction of ECT, the concern over adverse effects prompted research and Indian researchers did not fall behind in this clinic-academic venture. The studies included recording of physiological adverse effects on ECG, intraocular pressure as well as structural brain changes using neuroimaging. ECT passed this screening; sophisticated MRI-based neuroimaging studies failed to detect any brain changes acutely following ECT. Yet case reports of unusual side-effects such as catatonia, pneumothorax, CT-scan evidence of brain changes and even death following ECT have appeared in IJP. Traditional herbs may have the benefit of lowering the memory side-effects of ECT. Dr. Andrade even reviewed the molecular mechanisms of ECT-induced amnesia and possible interventions against such adverse effect. Coexisting medical (even neurological) conditions had usually discouraged clinicians from use of ECT. Observations suggest that ECT can be safely used against psychiatric disorders against the odds of a risk associated with concurrent medical condition. However, this may need additional monitoring mechanisms and expertise.
Electroconvulsive therapy stimulus
The first report of ectonus type of stimulus has been mentioned earlier. The stimulus laterality has been explored. Bilateral ECT remains the most popularly used as observed in surveys. A model ECT machine of sine wave type of stimulus was assembled and its scientific description appeared in the IJP. It may be remembered that sine wave ECT stimulus is nearly obsolete. A national workshop on ECT, in 1989, suggested designing of indigenous but state-of-the-art ECT machine with pulse stimulus waveform. Very recently, a comparative review of ECT machines of such stimulus output was reported. The author expressed some concerns and a need for a regulatory body for the standards of ECT device
Monitoring the seizure
Technological advances saw the introduction of EEG monitoring. Initial studies focused on the standardization of EEG monitoring procedures. This included the measurement of ECT seizure duration reliably by noting the change in the seizure morphology. Though EEG monitoring conferred some benefits over mere motor seizure monitoring, the former did not attract ECT practitioners as it carried inherent difficulties, additional expertise, time and cost, to mention a few. Paperless (computer-aided) seizure monitoring may be less cumbersome by avoiding the use of roles of ECT paper.
An alternative physiological measure was also explored, to aid reliable estimation of physiological seizure in ECT, as the behavioral seizure (convulsion) may be missed or is attenuated with modification procedures. Cardiovascular response demonstrated success as a potential alternative; sharp drop in the heart rate following the induction of convulsion marked the end of seizure. Some EEG measures in seizure could be extracted and these had value in predicting the efficacy of ECT.
Other issues regarding electroconvulsive therapy
Surveys of ECT practice by Indian psychiatrists indicated that we differ from Western practice as regards the frequency of use of modification, choices of conditions prescribed ECT and the ECT stimulus devices. The attitudes of patients and their relatives to ECT have attracted research. The fact that patients as well as their relatives have a favorable attitude towards ECT may also have allowed more patients to receive and benefit from ECT; and hence, contribute to the bulk of ECT research publications.
Anything left?
The mechanisms of action of ECT have been poorly explored as seen in the published ECT research. Some animal research has appeared pointing to dopamine receptor changes following electroconvulsive shocks (a model of clinical ECT). Among human studies, the publications included comparison of DST results and platelet 5-HT uptake between ECT and imipramine treated patients. Have researchers from India published more on this subject in other indexed journals? This area merits more investigation with the use of modern technology such as magnetic resonance spectroscopy.
NOTE ON THE SEARCH
A search was conducted in all volumes of Indian Journal of Psychiatry from 1959 till 2009. The search was carried out using the following key words: Electroconvulsive therapy, electroconvulsive, ECT, E.C.T. The study has included all studies related to humans, original articles, case series, case reports and excluded animal studies, review articles, editorials and letters that are not data-based, as they are opinions of various authors and not the real clinical data.
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MRI - T2 relaxometry of brain regions and cognitive dysfunction following electroconvulsive therapy. Indian J Psychiatry 2007;49:195-9. 27. Girish K. A survey on falling trends in ECT in a mental health trust in UK: Future implications. Indian J Psychiatry 2007;49:32. 28. Goswami U, Kumar U, Singh B. Efficacy of electroconvulsive therapy in treatment resistant schizophrenia: A double blind study. Indian J Psychiatry 2003;45:26-9. 29. Gupta UK, Mahendru RK, Mehta RK, Sonkar P. A comparative study of etomidate and thiopentone in modified ECT. Indian J Psychiatry 1986;28:151-4. 30. Gupta N, Avasthi A, Kulhara P. Response to first ECT in depression: A predictor of outcome. Indian J Psychiatry 1998;40:322-6. 31. Gupta N, Avasthi A, Kulhara P. Clinical variables as predictors of response to electroconvulsive therapy in endogenous depression. Indian J Psychiatry 2000;42:60-5. 32. Jain G, Kumar V, Chakrabarti S, Grover S. Use of electroconvulsive treatment in elderly: A clinical audit. 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Effects of ECT in enhancing quality of life in mania. Indian J Psychiatry 2007;49:35. 40. Kurian S, Tharyan P, Jacob KS. Combination of ECT and clozapine in drug-resistant schizophrenia. Indian J Psychiatry 2005;47:245. 41. Mahendru RK, Gupta UK, Mehta RK, Sonkar P. A comparative study of althesin and thiopentone in modified ECT. Indian J Psychiatry 1989;31:338-40. 42. Murali N, Sarvanan ES, Santosh MG, Gangadhar BN, Janakiramaiah N, Rao UM, et al. Cardiovascular response to ECT is unaffected by extent of motor seizure modification. Indian J Psychiatry 1999;41:236-41. 43. Murthy HN. Effects of electroconvulsive treatment on memory and intelligence in schizophrenics. Indian J Psychiatry 1966;8:138-42. 44. Pandey RS, Sharma P. ECT induced catatonia: A case report. Indian J Psychiatry 1988;30:105-7. 45. Selvan PC, Mayur PM, Gangadhar BN, Janakiramaiah N, Subbakrishna DK, Murali N. Comparison of therapeutic efficacy of ECT and Imipramine: A randomized controlled trial. Indian J Psychiatry 1999;41:228-35. 46. Phutane VH, Thirthalli J, Harish T, Gangadhar BN. Why do psychiatrists prescribe ECT to schizophrenia? Indian J Psychiatry 2007;49:33. 47. Ray SD, Kapur RL. Significance of some prognostic indices of schizophrenics treated with ECT and chlorpromazine. Indian J Psychiatry 1963;5:190-5. 48. ECT and Clozapine combination producing delirium: A case report. Indian J Psychiatry 2003;45:193. 49. Shah AV, Bagadia VN. Analysis of 5021 electroconvulsive therapies. Indian J Psychiatry 1961;4:129-38. 50. Shah VD, Mansur AM, Hakim IR, Mehd US, Mehta SH, Damany SJ. Cardiovascular and electrocardiographic changes after electroconvulsive therapy (ECT)-A series of 50 cases. Indian J Psychiatry 1977;19:51-3. 51. Shukla GD, Sharma VC. Evaluation of thiopentone, diazepam and propanidid in modified ECT. Indian J Psychiatry 1979;21:60-3. 52. Shukla GD, Sharma UC, Mehrotra AN. Intraocular pressure changes following modified ECT. Indian J Psychiatry 1980;22:274-6. 53. Shukla GD, Mishra DN. Death following ECT-A case report. Indian J Psychiatry 1985;27:95- 7. 54. Sivaprakash B, Chandrasekaran R, Sahai A. Predictors of response to electroconvulsive therapy in major depression. Indian J Psychiatry 2000;42:148-55. 55. Srinivasan TN, Suresh TR, Jayaram V. Issues in the use of maintenance electroconvulsive therapy. Indian J Psychiatry 1995;37:139-42. 56. Thakur A, Dutta S, Jagadheesan K, Sinha VK. Electroconvulsive therapy in pre-pubertal catatonia: A case study. Indian J Psychiatry 2001;43:354-6. 57. Tharyan P, Saju PJ, Datta S, John JK, Kuruvilla K. Physical morbidity with unmodified ECT-A decade of experience. Indian J Psychiatry 1993;35:211-4. 58. Thirthalli J, Gangadhar BN, Janakiramaiah N, Girish K, Ramakrishnan AG. Post-seizure EEG fractal dimension and spectral power predict antidepressant response to unilateral ECT. Indian J Psychiatry 2003;45:16-20. 59. Thomas N, Suresh TR, Srinivasan TN. Electroconvulsive therapy in catatonia associated with pneumothorax. Indian J Psychiatry 1994;36:91-2. 60. Trivedi JK, Singh RP, Lal N, Viswanathan PN, Kumar S. Effect of imipramine and ECT on platelet MAO activity in depressives. Indian J Psychiatry 1989;31:139-43. 61. Varma SL, Lal N, Trivedi JK, Anand M. Dexamethasone suppression test in depressives treated with ECT. Indian J Psychiatry 1987;29:353-7. 62. Varma SL, Trivedi JK, Anand M, Gulam R, Lal N. Post dexamethasone plasma cortisol levels in depressives treated with imipramine and electroconvulsive therapy. Indian J Psychiatry 1989;31:78-82.
Bangalore N. Gangadhar Jagadisha Thirthalli Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, India, Vivek H. Phutane Post-Doctoral Associate, Department of Psychiatry, Yale University of School of Medicine, Connecticut Mental Health Centre (CMHC), New Haven, Connecticut, USA 57 Psychotherapy in India: A journey through Indian journal of psychiatry
L. S. S. Manickam
ABSTRACT
The articles that appeared in Indian Journal of Psychiatry were related to different areas of psychotherapy. Case reports dealt with a wide variety of cases. The review papers focused on the suitability of psychotherapy in the Indian context, different approaches in psychotherapy, psychotherapy training and supervision. Psychotherapy has been viewed very close to faith orientation. There were attempts to identify the indigenous concepts that are applicable to psychotherapy. Empirical studies are low in number. Concerted effort is needed to generate interest in psychotherapy, conduct more research on evidence-based therapies as well as on psychotherapeutic process variables.
Key words: ???
INTRODUCTION
The path it has traversed thus far
Psychotherapy research has entered a new phase in the new century with more than 450 different therapies. From experiential and introspective narrations, it has taken a different turn with more evidence-based research appearing in the recent years in the Indian Journal of Psychiatry (IJP), spanning the period from 1959 to 2007.[1-3] Search for psychotherapy yielded 92 results in the IJP. On the other hand, search for 'psychotherapy research' showed 31 results which included case reports, editorials as well as book reviews. However, abstract search showed no results for the key word 'psychotherapy research'. Research studies related to psychotherapy process variables like empathy did not come up while searching for psychotherapy.
The psychotherapy articles that appeared in the IJP can be considered as occurring in three different phases in relation to the theoretical allegiance it has taken - initial phase, middle phase and the current phase. In the initial phase there were more articles related to psychoanalytically-oriented concepts. In the middle phase the articles were related to different theoretical concepts-psycho dynamically oriented, humanistic and existential. In the current phase, there are articles that take more of an eclectic and integrative stance. However, all through these phases, one finds an attempt to integrate indigenous concepts in the application of psychotherapy - The one appearing as early as in 1959[1] to 2004.[4] Analysis of the nature of articles that came up in the search showed that it included those articles that mentioned the need for psychotherapy in different form of disorders too.[5,6]
CASE REPORTS
The case reports that appeared showed a wide variety of cases. One of the earlier reports in 1958 was related to the successful treatment of a patient with schizophrenia using psychoanalytically-oriented psychotherapy.[7] Rao reported a case that was treated with Existential therapy in Anxiety Neurosis without medication.[8] The other reports have used psychotherapy as an adjunct in different disorders and the application of psychotherapy with in- patients with schizophrenia.[9] Supportive Psychotherapy was used as an adjunct to treat 'factitious schizophrenia'[10] whereas insight-oriented psychotherapy was used as an adjunct to treat Dermatitis artefacta.[11] One of the case reports published was from Brazil wherein the psychopathology of flash backs in social anxiety disorder was discussed. [12] Nagaraja narrated how psychotherapy was effectively used in treating adolescents in Hysterical Twilight state. [13] Bassa analyzed the cases at child psychotherapy centers; however, there is no mention of psychotherapy among children.[14] He suggested the need for orientation of pediatricians towards psychogenesis of various disorders to help prevent 'psychosomatic disorders'. In another case report, childhood sexual abuse was brought out in five adults during the process of supervised psychotherapy.[15] Bastani reported group psychotherapy with male genital exhibitionists conducted in US.[16]
DIFFERENT APPROACHES IN PSYCHOTHERAPY: CROSS ROADS
Psychotherapists in the Indian context face various dilemmas. Even as early as in the 1950s, Nand acknowledged the 'split' of psychiatrists into biologically- oriented and analytically-oriented.[1] Later, many others later observed that psychotherapy, as practiced in the West, might be suitable only for those living in cosmopolitan cities of India and not for majority of the population.[17-24] It was felt that one has to not only use a tool that is 'alien' to the culture, but also the socio-cultural milieu, which at times appears contradictory to the basic tenets of psychotherapy. Surya and Jayaram pointed out that the Indian patients are more dependent unlike Western patients who look for integration of intra psychic processes; there is a tendency for dissociation between thinking, feeling and acting and may block the process of psychotherapy. [20] Neki discussed confidentiality and privacy in the Indian context and opined that these terms do not even exist in Indian Languages and, in the socio-cultural context; the concepts of privacy could severe people from interdependent society.[17] Therefore, he recommended family therapy or at least couple of sessions with the family members along with dyadic therapy in order to help the progress of the psychotherapy.
Verma raised objections to the applicability of the Western type of psychotherapy in India.[19] He pointed out seven distinct features of the Indian population, which may not help psychotherapy work in the Indian context in comparison to the western population. They are as follows:
1. Dependence/interdependence. 2. Lack of psychological sophistication. 3. Social distance between the doctor and the patient. 4. Religious belief in rebirth and fatalism. 5. Guilt attributed to misdeeds in past life. 6. Confidentiality. 7. Personal responsibility in decision making.
He also viewed that the history of psychotherapy in India shows that it differed from the West in the following lines:
1. It was not meant only for the sick. 2. The patient and the therapist cannot be considered equals and hence dyadic relationship is not possible. 3. The patient has to accept what the therapist considers as 'truth'. 4. Everyone is not considered fit for psychotherapeutic relationship.
However, with globalization, increasing levels of education, higher sense of awareness on human rights and the wider use of electronic media even among the rural population, whether these observations stand today is a pertinent question. Varma and Ghosh,[23] in a study, of the practice of psychotherapy, on 32 Fellows of the Indian Psychiatric Society, found that short-term supportive therapy was used by majority of them. Some practiced other forms of psychotherapy including psychodrama.
On the other hand, Shamasunder held the view that psychotherapy can be effectively conducted on the Indian population.[24-27] Rao practiced existential psychotherapy and substantiated that the existential philosophy is not alien to 'Eastern' culture and can be used effectively.[7] He also argued that those who took a stance against the suitability of 'Western Psychotherapy' in Indian culture were focusing their arguments based on the psychoanalysis and not on other forms of psychotherapy of Western origin and emphasized that existential philosophy is very much closer to the Indian philosophical psychology.
However, the need to give adequate importance to psychotherapy, not only in treating psychiatric disorders but also from a public health perspective, in developing countries is also highlighted.[28-31]
REPORTS FROM ABROAD
Dreikers observed the usefulness of Adlerian psychotherapy in correcting faulty social values based on his experience in USA.[32] Cameron[33] wrote in 1961 based on his experience of practicing psychotherapy in Canada, "psychotherapy is undoubtedly the most widely used therapy within the field of psychiatry," which may not go well with the situation in India. Errazquin, in his review, observed the usefulness psychotherapy in treating psychoses.[34] Lesse, who is trained in psychoanalytically-oriented psychotherapy reported on specially designed psychotherapeutic procedures used in combination with drugs, useful for out patients with different psychiatric disorders. He advocated psychotherapy to be used intentionally secondary to the administration of drugs.[35] Stringham's article provides an overview of psychotherapy.[36]
FAITH ORIENTATION AND PSYCHOTHERAPY
Psychiatrists practicing psychotherapy in India have published the influence of religion as an essential 'ingredient' of psychotherapy from the very early days. Nand compared scientific psychotherapy with 'Religious Psychotherapy'. [3] He observed 'Shivite symbol' as one fixed symbol for Indian culture. Based on the case records of Indian patients, of Hindu faith, he compared it with the phallic symbols represented at the temples at Banaras. While discussing 'total psychoanalysis,' he drew parallel between the symbols 52(1), Supplement 2010 that Freud brought in from his religious and cultural traditions into psychoanalysis and explored its counter part in the Indian patients. While doing so, he suggested the need to strengthen religious therapy as well as 'race therapy' and explore the psychopharmacology of the change agents in psychotherapy. Hosseini described how Islamic principles could be used in psychotherapy.[37] Hoch too examined the way Pirs and Faquirs function as therapists and interpreted the indigenous concepts involved in their practices as 'therapists' that worked with illiterates.[38]
Psychotherapy concepts from Indian philosophical psychology: Energy from ancient tradition?
One finds that as early as in 1961 there have been attempts to integrate indigenous concepts in the application of psychotherapy.[3,39] Nand has brought in the 'Shivite' symbols in psychoanalysis. Surya and Jayaram observed that the legend of Savitri provides the framework of psychotherapy.[20] Verma viewed psychotherapy as, the 'interpersonal method of mitigating suffering' and found its roots in the communication of Buddha; he also emphasized the use of concepts of Karma and Dharma in psychotherapy.[19] Neki used the concept of Sahaja.[18] He considers the healthy woman personality possessing- illumination, equipoise, spontaneity, freedom and harmony- a higher state of positive mental health as manifested through Sahaja. He also discusses the potential of various other Indian concepts including nirvana. One of his concepts is related to relationships in psychotherapy- Guru-chela, which he viewed as a therapeutic paradigm.[22] Patanjali yoga as a therapy had also been used.[40,41] Wig used the term Hanuman complex[4] and the mythology for helping the patients and the doctors understand about process of psychotherapy. The therapist quality of Sahya is another concept from Indian thought that has to be explored.[42]
Psychotherapy training
There is an increased demand from psychotherapy trainers and trainees for better psychotherapy training procedures. [26,27] However, reports on psychotherapy training are very meager.[43,44] Rao[8] delineated five reasons for the neglect of psychotherapy training in India. He observed that:
1. Psychotherapy is highly subjective and individualistic. 2. Novelty of the psychological and philosophical concepts to the trainee. 3. Impracticability of Analysis of the trainee as required by some psychoanalytically oriented approaches. 4. Time required for training that extends beyond the training period; and 5. Lack of inclination among trainees.
The availability of trainers who are inclined, interested and committed to impart the psychotherapeutic skills is reiterated by many psychiatrists.[8,24,43] The number of training centers that devote time on psychotherapy is also few. Shamasundar opined that in the absence of a wide network of specialist psychotherapy services in the country, it is imperative for the general psychiatrist to have a 'working knowledge of psychotherapy'. Psychotherapy training needs to form an essential part of psychiatric training.[24] He suggests the inclusion of psychotherapy training as a desirable component of all medical postgraduate training.
Supervision in psychotherapy
Psychotherapy training requires a strict supervision of the work of the young therapist by an experienced therapist. The young therapist in our country, many a times, is not giver adequate supervision and the final product is a therapist without adequate skills.[26] Shamasunder appealed for active, supervised training in psychotherapy for junior and trainee psychiatrists.[26] The supervising task becomes more cumbersome due to multilingual nature of the patients, trainees and trainers. Tharyan, in an experiment, showed that group supervision is feasible and acceptable in a general hospital psychiatry set up in India though it cannot replace individual supervision.[43]
Psychotherapy research
Dhairyam made an early call for psychotherapy research. [45] However, there is paucity of literature related to psychotherapy process and outcome research undertaken in our country. More than two decades ago Neki suggested that research on process variables to be initiated, in order to develop a unique perspective on psychotherapy in our country that is congruent to our culture including that of mauna.[18] There appear to be no takers to the challenge and this could be due to various factors. One of them could be very few training centers of psychotherapy in our country. Even in the existing centers, lack of sophisticated gadgets required to conduct a well- designed control study might have prevented researchers from taking up studies related to psychotherapy variables.
Case control studies on psychotherapy
Two of the earliest studies are those of Balakrishna et al. [40] and Vahia.[46,47] Balkrishna and his associates studied the effect of Patanjali yoga on 'psycho neuroses' and found it useful in stress induced psychological disorders. It showed better results than the drug treatment. Probably Vahia's studies introducing Patanjali yoga into psychiatry research was a landmark that led many others to take up yogic asanas and related yogic concepts for empirical research in the field of psychiatry and health.[46,47] In another case- controlled study, Kumar and Thomas assessed the effectiveness of brief psychotherapy in a sample of patients with alcohol dependence.[4] They concluded that a combination of psychopharmacological treatment with appropriate psychosocial therapies that is focused on the specific problem of the patient might provide better outcome than either of the therapies given alone. However, it was not a blind study and hence the results obtained may have been confounded by other variables too.
Psychotherapy process variables
Research on empathy was conducted on different professional groups, - psychiatrists, clinical psychologists, psychiatric social workers and lay counselors.[48,49] Though the study was conducted using simulated client, the participants of the study perceived the simulated client similar to that of a real client.[50] Self perceived empathy and emotional empathy were also explored.[51-53] Though professionals reacted positively to audio taping of the sessions.,[54] it is not widely used in training. Videotaping of the sessions involving the trainees is used. During clinical training, in psychotherapy, audio taping/videotaping of the therapy sessions are not mandatory and hence there is lack of adequate material to conduct research. Even as early as in 1974, videotapes were used in group psychotherapy sessions with male genital exhibitionists and the group dynamics is reported by an Indian researcher in USA.[16] We are yet to make use of the technology in clinical practice and research. The lack of research could be due to several factors: Time restraint, lack of facilities, inadequate supervised training and client's perspectives about secrecy, privacy and stigma. However, the impact of therapist variables on patients has not been conducted so far.
Where do we go from here?
There are very few studies on psychotherapy process or out come research in India. The reason for less number of research studies appearing in India may be a reflection of the priority of research in psychiatry in India. The course curriculum is one of the factors that could make a change in the scene. Psychotherapy is included in the curriculum of postgraduate training in psychiatry. However, there are no guidelines available at the national level on how and what skills need to be imparted. Introducing psychotherapy case submissions with adequate supervision as part of the curriculum is likely to generate the interest and improve the skills of the trainee psychiatrist.[27] Psychiatrists, who were trained through the curriculum wherein case submissions of psychological assessment were mandatory, had a better know-how of the relevance and usefulness of the psychological assessment tools. That probably led to the development as well as adaptation of new tools independently or in association with the fellow professionals. Psychotherapy supervision groups that have been found to be successful in some of the training centers may be started in other training centers too. Evidence-based psychotherapies are likely to be better accepted among the new entrants. Psychotherapy is moving towards integration of psychotherapies with divergent theoretical approaches. Unless there is exposure to different forms of psychotherapy, it may be difficult to integrate the concepts that are theoretically contradictory.
The road ahead
Practicing psychotherapy is an interesting journey and supervision of psychotherapy, though emotionally taxing on the supervisor, is all the more interesting. Those who start off the journey hardly turn back, despite being pressurized with the demands of time and energy. All may not be willing to plunge into the journey. However, those who are willing may be facilitated to begin it with adequate and appropriate supervision. More number of trained psychiatrists who can strike a balance between the biological determinants of behavior and are willing to understand the psychopathology is likely to increase the number of research related to different approaches of psychotherapy. Indian philosophical psychology is a treasure to be unearthed in understanding the 'person' as well as in helping, but lacks empirical research evidence. Agarwal wrote two decades ago, "Psychotherapy which dominated psychiatry for long seems to have become relegated into oblivion".[31] And through the journey of the IJP, so far, it is found to be true. Probably the new millennium might make the road smoother by publishing more research on evidence based psychotherapies that are suitable for the advantaged and the disadvantaged population of our country and thereby making a positive difference in the life of those who are suffering.
REFERENCES
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Practical steps in existential psychotherapy and one year follow-up of a case. Indian J Psychiatry 1990;32:244-51. 9. Gralnick A. In-patient psychoanalytic psychotherapy of schizophrenia: Problem areas and perspectives. Indian J Psychiatry 1962;4:177-88. 10. Grover S, Kumar S, Mattoo SK, Painuly NP, Bhateja G, Kaur R. Factitious schizophrenia. Indian J Psychiatry 2005;47:169-72. 11. Tamakuwala B, Shah P, Dave K, Mehta R. Dermatitis artefacta. Indian J Psychiatry 2005;47:233-4. 12. Kummer A, Harsanyi E. Flashbacks in social anxiety disorder: Psychopathology of a case. Indian J Psychiatry 2008;50:200-1. 13. Nagaraj J. Hysterical twilight and fugue state in early adolescence. Indian J Psychiatry 1969;4:46-8. 14. Bassa M. An analysis of cases attending child psychotherapy. Indian J Psychiatry 1962;4:139-44. 15. Jain S, Vythilingam M, Eapen V, Reddy J. Psychotherapy and childhood sexual abuse. Indian J Psychiatry 1992;34:389-91. 16. Bastani JB. Group psychotherapy with male genital exhibitionists. Indian J Psychiatry 1974;16:316-22. 17. Neki JS. Editorial: Confidentiality, secrecy and privacy in psychotherapy: Sociodynamic considerations. Indian J Psychiatry 1992;34:171-3. 18. Neki JS. Psychotherapy in India. Indian J Psychiatry 1977;19:1-10. 19. Varma VK. Present state of psychotherapy in India. Indian J Psychiatry 1982;24:209-26. 20. Surya NC, Jayaram SS. Some basic considerations in the practice of psychotherapy in the Indian setting. Indian J Psychiatry 1968;4:153-6. 21. Sethi BB, Trivedi JK. Psychotherapy for the economically less privileged classes (with special reference to India). Indian J Psychiatry 1982;24:318-21. 22. Neki JS. Guru-Chela relationship: The possibility of therapeutic paradigm. J Orthopsychiatry 1973;43:755-66. 23. Varma VK, Ghosh A. Psychotherapy as practised by the Indian psychiatrists. Indian J Psychiatry 1976;18:177-86. 24. Shamasundar C. Some personal reflections relating to psychotherapy. 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Indian J Psychiatry 1961;3:6-14. 34. Errazquin SJ. Psychotherapy of psychoses. Indian J Psychiatry 1961;3:83-9. 35. Lesse S. Psychotherapy in combination with tranquilizers and antidepressant drugs. Indian J Psychiatry 1978;20:120-31. 36. Stringham JA. Some experiences with psychotherapy. Indian J Psychiatry 1966;8:8-20. 37. Hosseini SA. An elementary study of the principles of individual and group psychotherapy and mental health in Islam. Indian J Psychiatry 1983;25:335-7. 38. Hoch EM. Pir, faquir and psychotherapists. Human Context 1974;6:668-76. 39. Bhaskaran K. Meditation from a mental health prospective. Indian J Psychiatry 1991;33: 40. Balkrishna V, Sanghvi LD, Rana K, Doongaji DR, Vahia NS. The comparison of psychophysiological therapy with drug therapy. Indian J Psychiatry 1977;19:87-9. 41. Vahia NS, Jeste DV, Kapoor SN, Ardhapurkar I, Nath RS. Further experience with the therapy based upon concepts of Patanjali in the treatment of psychiatric disorders. Indian J Psychiatry 1973;15:32-7. 42. Manickam LSS. Sahya: The concept in Indian philosophical psychology and its contemporary relevance. Yoga and Indian approaches to psychology. In: Joshi K, Cornelissen M, editors. New-Delhi: Centre for the Study of Civilizations; 2004. 43. Tharyan A. An experiment in psychotherapy training. Indian J Psychiatry 2000;42:142-7. 44. Kapur M, Shamasundar C, Bhatti RS. Psychotherapy training in India. Bangalore: NIMHANS Publications; No.36, 1996. (Revised Edition 2002). 45. Dhairyam D. Research need for development of psychotherapy. In: Menon TK, editor. Recent trends in psychology. Mumbai-Calcutta-Madras-New Delhi: Orient Longmans. 46. Vahia NS, Vinekar SL, DV, Doongaji DR. Some ancient Indian concepts in the treatment of psychiatric disorders. Br J Psychiatry 1966;112:1089. 47. Vahia NS, Doongaji DR, Deshmukh DK, Vinekar SL, Parekh HC, Kapur SN. A deconditioning therapy based upon concepts of Patanjali. Int J Soc Psychiatry 1972;18:61-6. 48. 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L. S. S. Manickam Department of Psychiatry JSS University JSS Medical College Hospital Mysore - 570 004, India 58 Indian contribution to behavior therapy
K. Kuruvilla
ABSTRACT
Publication of papers related to psycho-social interventions in general and Behavior Therapy, in particular, in Indian Journal of Psychiatry has been limited. Though the first paper related to Behavior Therapy was published in 1952, a manual search of all available issues of the journal from 1949 showed that only 42 papers related to Behavior Therapy have been published till 2009. Among them 10 are case reports. Methodological limitations abound even in the papers on larger groups of patients. Studies using operant conditioning have been very few. Aversion therapy and progressive muscle relaxation have been very frequently used. The published articles are reviewed under the various diagnostic categories. Publications in the recent years have been mostly on Cognitive Behavior Therapy. Even after 57 years of co-existence, the relationship between Behavior Therapy and Indian Psychiatry remains a tenuous one.
Key words: Behavior therapy, behavior modification, behavioral intervention, cognitive therapy, cognitive behavior therapy
INTRODUCTION
One of the characteristics of psychiatry, as practiced in India, is the extremely limited use of psycho-social methods of treatment. In 1973, when Varma and Ghosh[1] did a survey on the practice of psychotherapy among Fellows of Indian Psychiatric Society, only 17% of them reported to be using any psychological method of treatment. Today we have a much larger number of psychiatrists in this country, but the percentage of those using psychological methods of treatment is unlikely to be much greater. This limited use of psychological method in clinical practice (even in academic centers) is reflected in the publications in this area. It is found that among the papers published in Indian Journal of Psychiatry (IJP) only about 2% deal with psycho- social methods of treatment, in comparison to 16% in the British Journal of Psychiatry.
The above observation on psychological methods of treatment in general is also true with regard to Behavior Therapy (BT) or any of its variants. Most psychiatrists in India, I feel, will admit that these psychological methods are useful or even essential in some psychiatric disorders but many of them do not have either the time or inclination to practice them. Often such patients are referred to psychologists or social workers who are interested in psycho- social methods of treatment. So it is likely that publications like Indian Journal of Clinical Psychology may have many more papers on BT than Indian Journal of Psychiatry. However, the present article is not an attempt to review the state of BT in India, but is a more restricted attempt to review articles published in Indian Journal of Psychiatry since it will more accurately reflect the Indian psychiatrists' attitude towards BT.
Method of search for articles
Using the key words 'Behavior Therapy' on the IJP web site yielded a list of 42 articles related to the topic. However, when one went through the list only nine articles were found to have anything to do with BT and the rest were on totally unrelated topics ranging from 'ECT and clozapine' to 'psychotic symptoms in acromegaly'!
So a manual search was done through the contents of all available issues of Indian Journal of Neurology and Psychiatry (1949 to 1953) and Indian Journal of Psychiatry (1958 to 2008) in the DVD published by Indian Psychiatric Society. Contents of the three issues of the Journal published in 2009 were also searched. Articles which contain words like - Behavior therapy, behavior modification, behavioral intervention, cognitive therapy, and cognitive behavior therapy, biofeedback, relaxation training, which are related to BT, were searched. In addition, if the title of the articles suggested the possibility of BT use, for example 'Treatment of Trichotillomania,' then the articles were given a detailed look to see whether the authors have in fact used BT and those papers were also selected.
In the beginning
The article which could be considered the first on this topic was authored by Ganguly[2] in Indian Journal of Neurology and Psychiatry in the year 1952. It was entitled "Pavlov's Influence on Psychiatry" and discusses 'Pavlovian Reflexology' and introduces the concepts of conditioned reflex, experimental neurosis etc. and suggests that these concepts can help psychiatrists in understanding and treating disorders like hysteria, obsession, paranoia and psychosomatic disorders. The author reported that he was working on asthma and peptic ulcer on Pavlovian lines and expressed the hope to publish the results at a future date. However, we do not have any information on the fulfillment of this promise.
It may come as a surprise to many readers, especially of the older generation, that Satyanand[3] who has written extensively on psychoanalytically oriented psychotherapy in the Indian context, also has written an article on 'Recent Advances in Behavior Therapy'. Initially the paper deals with psychotherapy in general and the need to use it in psychiatric practice and then introduces BT which at that time was not a well known system of therapy. The author concludes: "If the medical man wants to work out psychotherapeutic sessions on his own, he will find it easier to follow the Behavior Therapy and Reconditioning Therapy".
Skepticism about the newly emerging treatment method is evident in Neki's[4] review of a book called 'Behavior Therapy in the 1970s'. He writes, "broader basic principles, more complex psychopathological models and therapeutic procedures with wider range of effectiveness need yet to be developed and social learning, cognitive mediating mechanisms related to attitudes, value systems and self concepts need to be incorporated in to the practice of behavior therapy". This sagacious advice became a reality in the next decade with the advent of Cognitive Therapy (CT) and the fusion of cognitive therapy and behavior therapy in to Cognitive Behavior Therapy (CBT).
In the early 1970s BT was still a new entrant in to the field of psychiatry in India. This is evident from the two articles by Chopra.[5,6] In the first one, Jacobson's Progressive Muscle Relaxation (JPMR) is introduced to Indian readers as "treatment for neurotic states in which anxiety and phobic features are predominant" and also mentions it as a part of 'systematic desensitization'. The technique is illustrated through case reports. In the second article, treatment of 11 patients with disorders like agoraphobia, obsessive compulsive disorder and frigidity with systematic desensitization is described.
All 11 patients improved (six markedly improved) with the treatment. On follow-up varying from one month to two years only one patient was found to have relapsed. Though published in IJP, the papers were based on the author's work in Australia. It is interesting to note that Chopra as well as other authors at that time, while talking about outcome on follow-up usually added "there was no symptom substitution," perhaps to counter the criticism of psychoanalytically oriented therapists who held that BT is only removing symptoms at a superficial level and since the deep seated conflicts are not dealt with, the patient will invariably present with some other symptoms at a later date.
General characteristics of behavior therapy articles published in IJP
1. BT was the first psychological method of treatment which showed that its therapeutic efficacy can be established by rigorous scientific methods of evaluation like randomized, placebo-controlled, double blind studies, instead of merely relying on the subjective opinions of patients and therapists. It has shown that methodological issues like sample size, randomization, use of controls, masking of the assessor, valid outcome measures, determination of statistical as well as clinical significance of outcome etc. are important and feasible in evaluating efficacy of psychotherapeutic methods also. But when we go through the published studies in India it becomes obvious that we have not paid attention to such methodological issues.
2. Out of the 42 articles related to BT till 2009, 10 are single case reports. In a newly emerging model of treatment single case reports have a place. BT papers by western workers have shown that efficacy of treatment technique can be more convincingly demonstrated, even in a single case by following an A-B-A-B design. But none of our case reports have included such a step.
3. Main model of BT as practiced in India seems to be classical conditioning. Operant conditioning which has emerged as a more versatile and effective approach and has a greater degree of acceptance by patients, has few adherents here.
4. Excessive reliance on aversive techniques is seen in many of the studies in a wide variety of disorders-hysteria, homosexuality, tremors, titubation etc. It is interesting to note that even in the 1970s, in the 'Instructions to Authors" in the well known BT journal, 'Behavior Therapy and Experimental Psychiatry' (edited by Joseph Wolpe), it was stated that repots using aversion therapy techniques will not be accepted, unless no other proven method of treatment exists for that condition.
5. Jacobson's Progressive Muscle Relaxation (JPMR) is used as a part of BT in almost all conditions ranging from nail-biting to schizophrenia! Justification for its use is not given in many of the papers, so much so, even in some of our academic institutions JPMR is considered to be synonymous with BT, even to the extent of postgraduate trainees in psychiatry who are posted in Behavior Therapy units getting trained only in JPMR. 6. Many of the reports show that every behavioral technique described in a standard text book on the subject is used for every disorder, often without justifying such a multipronged approach, which reduces the cost effectiveness of the therapy and its application in settings with limited time and trained personnel.
Behavior therapy in specific disorders
Sexual dysfunction
Agarwal's[7] paper in 1970 described the treatment of erectile dysfunction (ED) and premature ejaculation (PE). Treatment consisted of sex education, assessment of marital relationship and 'deconditioning' which resulted in improvement in nine out of the 11 patients. Though the author does not use the term BT and emphasizes the psychotherapeutic aspects of the treatment in the discussion, the procedure described as 'deconditioning of the faulty ejaculation response' is very similar to behavioral techniques used in sex therapy. Behavioral techniques described by Wolpe were used by Kuruvilla[8] in the treatment of 18 men with SD and 8 with SD and PE. All were treated along with their wives by a single therapist. At the end of the treatment, 54% were much improved, and others were partially improved, as reported by patients and their wives independently. At follow-up all but one of the 'much improved' persons maintained the improvement. Bagadia et al.[9] treated 26 patients with PE and secondary ED with BT. Wives of only 11 patients attended therapy sessions. Yet 58% of patients improved. The authors opine that wives not coming for treatment sessions does not necessarily indicate marital disharmony in most of the patients and a wife who is unable to attend the sessions may still help in the treatment by following instructions sent through the husband. Gupta et al.[10] treated 21 married couples belonging to urban middle class and engaged in white collar jobs, with what the authors called as "modified Masters and Johnson technique" because only one therapist was involved and psychoanalytical principles also were used. 76.2% were reported to have "recovered". The authors attribute the better outcome, in comparison to other studies, to the use of psychoanalytical concepts in addition to BT. But other factors like difference in sample characteristics also could have led to the difference in outcome.
In an attempt to help unmarried men who present with ED, but were unable to go through the classical Masters and Johnson sex therapy, because of the lack of a partner, Kuruvilla[11] introduced the technique of guided imagery and masturbatory conditioning with the help of erotic reading material. Relaxation training and sex education were given prior to these steps to reduce the sexual misconceptions and associated high anxiety level. Among the 18 patients without a partner who were offered this treatment, 13 completed the course. Response was rated as 'good' in nine and 'partial' in four. Eleven of the completers could be followed up for six months to two years and at the time of last follow-up contact seven of them were completely free from the erectile problem.
The above reviewed studies highlight some of the modifications introduced by Indian therapists to deal with certain special difficulties encountered in our country, in the treatment of sexual dysfunctions.
Disorders of sexual preference
In the 1970s and 80s, men with ego-dystonic homosexuality often came to Indian psychiatrists for help and behavioral techniques were used in treating such persons. Sakthivel et al.[12] treated four men who voluntarily approached them for treatment to get rid of their homosexual orientation. They were treated with anticipatory avoidance technique. These men also experienced high anxiety levels when they had to interact with females. This was treated by desensitization. They were followed up from 5 to 10 months. At follow-up, all reported being free from homosexual behavior and having heterosexual interests. One was happily married. 61% of the13 males with homosexual orientation treated by Pradhan et al.[13] with electrical aversion for homosexual imagery and positive conditioning for heterosexual imagery, reported change in sexual orientation. Patients' motivation to change was found to be the main factor associated with good outcome. Mehta et al.[14] treated six persons with homosexual orientation with 'double differential conditioning,' which consisted of pairing Faradic electrical aversive stimuli with homosexual fantasy and music with heterosexual fantasy. Social skills training and supportive psychotherapy also were given. Four of the treated individuals achieved a change in sexual orientation.
A case of frotteurism was treated by Kuruvilla et al.[15] with systematic desensitization in imagery and in-vivo for eliminating the avoidance behavior to social situations which produced anxiety in him because of frotteurism. Frotteurism itself was treated with exposure to situations of bodily contact with males in imagery and in-vivo and also aversion therapy. Symptoms were eliminated in 10 sessions. This patient was followed up for one year when he was found to have no anxiety in social situations and no indulgence in frotteurism. BT consisting of relaxation training, aversion therapy with aversion relief, modeling, orgasmic reconditioning, behavioral counseling and sex education, was used by Andrade et al.[16] for a patient with trans- sexualism and homosexual orientation. Therapy resulted in normalization of gender identity, but homosexual orientation persisted. Obsessive compulsive disorder
Nammalvar et al.[17] treated 17 patients with a diagnosis of obsessive compulsive disorder. In the first phase, they were taught progressive muscle relaxation, to be practiced at home regularly. Thought stopping was introduced in the second phase. Therapeutic change was measured using Taylor's Manifest Anxiety Scale and Beck Depression Inventory before and after each phase. 65% of the patients showed marked reduction in the frequency of obsessions and the distress caused by them. There was also significant reduction in anxiety and depression. Good outcome was found to be associated with short duration of illness and low level of depression. On follow-up, ranging from one to four years, 10 out of the 11 who showed improvement were found to maintain the improvement. The paper does not give any information on the effect of treatment on the compulsive symptoms some of these patients had or whether some other treatment method was used to deal with them. In another paper on the same group of patients, these authors[18] suggest the phenomenon of habituation as the explanation for the effectiveness of thought stopping. In the absence of empirical data this remains a hypothesis only. Pradhan et al.[19] treated 28 cases of OCD with a BT package and good results were seen in 15 (53%) of them. Therapeutic procedures included relaxation training, thought stopping, implosion, modeling, response prevention, electrical aversion and positive reinforcement. Psychological tests like Hamilton Anxiety Rating Scale, Rorschach Ink Blot test and MMPI were administered before and after treatment. Improvement with BT was not reflected in the post-treatment performance on these tests. Shorter duration of illness was related to better outcome. No information was given on the effect of the package on obsessive and compulsive symptoms separately information or on concomitant use of medication. On follow-up, four months to two years later, 27% of those who had good outcome had relapsed. In a case report Singh et al.[20] describe use of BT techniques like thought habituation and exposure, along with pharmacotherapy (fluoxetine and thyroxine) in treating a 21-year-old male who presented with obsessive slowness. The symptoms improved in three months and remained so at nine-month follow-up.
Writer's cramp
Fernandez[21] reported 17 cases of occupational neurosis, including 13 cases of writer's cramp. These patients were treated with various methods like narcoanalysis, methedrine abreaction, hypnosis etc. "Prevention of habit formation by daily supervision and correction of handwriting style" also was part of the treatment. All patients were reported to "have improved sufficiently to adjust satisfactorily to their normal life". The Arora et al.[22] paper published in the Journal of Behavior Therapy and Experimental Psychiatry was the most influential paper on BT of writer's cramp. All subsequent studies from India have used the procedure described in that paper. Mehta et al.[23] brought out a large series of 30 cases of writer's cramp treated with BT consisting of relaxation, retraining and systematic desensitization (in some cases). Complete improvement occurred in 13 patients and partial improvement in 14. Good improvement was associated with good motivation, regular treatment sessions, insight in to the psychological nature of the illness and shorter duration. Another paper on three patients by John et al.[24] also reported good improvement in all three patients with supinator retraining. Chavan et al. [25] reported a series of 23 cases of writer's cramp with BT, individual psychotherapy and anxiolytic drugs. BT included JPMR and retraining exercises. Eight patients had only BT, four had BT and drugs, two had JPMR only, five had JPMR and drugs and two had only drugs. Only four patients showed good improvement; eight had no improvement at all. BT as treatment, short duration of illness, long duration of treatment involving frequent sessions were found to be factors associated with good outcome. Though these patients are reported to have had individual psychotherapy, no information is given about the indication for it and its influence on the outcome.
Anxiety neurosis
Biofeedback, which is often considered a BT technique, was used in the treatment of anxiety neurosis by Sargunraj et al. [26] Thirty six patients with a diagnosis of anxiety neurosis were given EMG biofeedback. Twelve of them were also on adjuvant medication. Biofeedback training resulted in lowered levels of EMG activity during mid and post-therapy assessments, but there were no concomitant changes in skin temperature, skin conductance level and response. Anxiety symptom score also decreased, but there is no mention of the clinical significance of this reduction.
Sahasi et al.[27] compared the effect of JPMR with yogic techniques of relaxation in the management of anxiety neurosis. Both groups showed significant reduction in anxiety levels, but greater improvement in state anxiety happened in the yoga group. Subjective improvement also was more in the yoga group. One drawback of this study was that the therapists themselves were the assessors of outcome. Reduction in symptom scores in the psychological measure of anxiety and self report by the subjects was achieved by EMG biofeedback assisted relaxation in a group of 22 persons with anxiety neurosis by Abraham et al.[28] but this was not reflected in physiological measures like GSR. Tension headache
Sethi et al.[29] compared the efficacy of biofeedback and shavasana in tension headache. Sixteen patients were randomly assigned to two groups after excluding physical cause for headache. Both the groups were treated for 10 weeks. Equal response was seen in both the groups. The authors use this finding to advocate greater use of yoga in the treatment of problems like tension headache, because it will be more effective in a country like India. However, it is to be noted that the sample size was small and the completers were only seven in the shavasana group and six in the EMG group. Only five from both the groups put together showed complete remission.
Five executives with tension headache were treated by Mehta[30] with JPMR supplemented by relaxation practice at home, and brief relaxation and cue relaxation during office hours. All five showed marked improvement both according to subjective report and daily headache diary.
Gada[31] compared the effectiveness of EMG biofeedback and JPMR in tension headache. Peak headache intensity, average daily headache activity score and headache free days were used as outcome measures. Both methods were found to be significantly effective. This study again highlights the appropriateness of a cost effective procedure like JPMR being used more widely.
Trichotillomania
Trivedi et al.[32] reported a case of trichotillomania initially treated with anti depressant medication and anxiolytics and then given psychotherapy, which improved his insight but did not reduce the urge to pull the hair. Then he was given BT, which involved bandaging both his hands for long hours to prevent hair pulling, making the patient to listen to music, reading books etc, as diversion from the repetitive behavior and positive reinforcement for refraining from hair pulling. Three weeks' of treatment resulted in good control of the habit and this was maintained at three months' follow-up.
In a more recent paper, Kaur et al.[33] reported three cases of trichotillomania treated with pharmacotherapy and BT consisting of JPMR, deep breathing exercise, distraction technique, response prevention, thought stopping and diary maintenance. Improvement occurred in all cases in three to four weeks. When followed-up six to seven months later, one patient was found to have a mild relapse which was controlled by further BT. Despite the impressive results, the application of far too many behavioral techniques makes it difficult to use them in ordinary clinical practice. The reader is left wondering, which of these techniques is the real effective ingredient! "Hysteria"
Seven females diagnosed with 'hysterical vomiting' were treated by Bhattacharya et al.[34] with electrical aversion, not only for vomiting during treatment session, but also for reported vomiting at home between sessions! All subjects stopped having the symptom. Authors refer to the controversy regarding the use of aversive techniques as treatment, but feel they are justified in resorting to them.
Vyas et al.[35] reported the use of aversion therapy in 'hysterical fits'. Thirty six patients were treated in two phases – First phase of inducing fits and second phase of applying aversive stimuli till the fits stopped. All reported to have been "cured" at the end of the treatment phase and 72.33% did not have any fit at follow-up six months later. The authors' conclusion, "aversion therapy is as good as any other mode of treatment for hysterical fits. It is less time consuming than other conventional psychotherpeutic and psychoanalytical procedures," may not be an adequate justification for its continued use in dissociative and similar disorders.
Nasirabadi et al.[36] reported about a young man who presented with seven episodes of hysterical aphonia in ten years. Each time he was brought to the hospital, faradic stimuli were given with electrodes placed on the throat and immediately patient would become symptom-free. It is stated that the patient's family wanted only symptom removal and did not want any therapy for the underlying psychological problems, perhaps indicating the undesirability of merely relying on the power of suggestion to remove symptoms.
Alcoholism
Forty eight alcoholics were treated by Bagadia et al.[37] with electrical aversion in groups of three, when one patient got the aversive electrical stimuli, the other two were expected to observe him. Each patient had a minimum of 20 aversion sessions. Outcome measures included not only abstinence, but also work, social behavior, reduction in daily consumption of alcohol, reduction in drunken days per week and reduction in urge to drink. Patients were followed up for six months to two years; 60.4% showed good improvement. Instead of confining to abstinence alone as an outcome measure, making use of other clinically significant measures of outcome is the strength of this paper. Details about concomitant pharmacotherapy are not given and their possible contribution to outcome not discussed. The rationale of making two patients watch the third one get aversion therapy is also not explained. Depression
Ten patients diagnosed to have 'neurotic depression' were given multi-modal BT by Kumariah.[38] Treatment included measures to increase activity level, reduce behavioral excesses, induct affects that are incompatible with depression and enhance instrumental skills given in18 to 31 sessions. Dysphoria and somatic complaints disappeared, behavioral excesses an deficits came down to optimum levels and patients described themselves to be "happy at work and in life" No rating scale for depression was used at baseline or follow-up.
Miscellaneous conditions treated with behavior therapy
The earliest case report on the use of BT, published in IJP was by Ratan Singh[39] who treated a 26-year-old man who used to tear and bite his nails and skin of finger tips almost continuously except when he was asleep. Initially the patient was treated with negative practice. Though the habit was controlled for some time, it recurred when the patient went back to his college. In the next phase of treatment, antecedents of the habit were identified as situations which made him anxious and apprehensive. JPMR was introduced and patient was asked to practice it in situations which made him bite the nails. This led to a remarkable improvement which was maintained at four months' follow-up.
Nammalvar et al.[40] treated 29 patients with assorted symptoms like aphonia, titubation, tremors, and belching of four to six months' duration. Electrical aversion was given for maladaptive behavior; shock was terminated when adaptive behavior occurred, which was also socially reinforced. Behavioral counseling was given was given to family members to reinforce adaptive behavior. Twenty five of the 29 persons recovered from the symptoms and remained so at follow-up nine to 14 months later.
A four-and-a-half year old child with an I.Q of 110, with encopresis for two and a half years, unable to even attend nursery school, was treated by Behre et al.[41] Basal rate of the problem behavior was established. Then positive reinforcement was introduced to promote successful elimination in to the toilet. If no bowel movement occurred no reward or punishment was given. Mother was required to give the reward as well as to chart the period of dryness. Improvement started after two weeks of therapy and in six months the child had completely stopped soiling himself. Inspite of being a single case report, this deserves attention because of the systematic way in which operant conditioning was introduced to eliminate a clinically relevant problem. Reevar[42] reported behavioral management of a case of 'hypochondriasis' with JPMR, behavioral counseling, and bibliotherapy. Clinical details given in the report raise doubts about the diagnosis and description of 'behavioral counseling' and 'bibliotherapy' are quite different from what is generally understood by these terms.
Advent of cognitive behavior therapy
The emergence of Cognitive Therapy (CT) as an effective treatment approach for many conditions like depression and anxiety disorders and its subsequent merger with BT to form Cognitive Behavior Therapy (CBT) has had its impact on the Indian scene also. There are a few psychiatrists and many psychologists practicing it, but publications in this field in IJP have been few. An early paper by Kuruvilla[42] on 17 patients with major depressive disorder showed that CBT can be practiced in Indian setting also. Of the 14 patients who completed the course, 11 showed marked improvement and three had partial improvement in depressive symptoms. Like any psychological method of treatment CBT also needs some modifications and adaptation to suit the culture in which it is practiced. This issue is dealt with in another paper by Kuruvilla.[43] In a review article on CBT, Kuruvilla[44] traces its origin, theoretical foundations, and early applications in conditions like depression, and anxiety disorders. Its current place in the treatment of psychotic conditions, dysthymia, obsessive compulsive disorder, personality disorders, hypochondriasis, PTSD, alcoholism etc. are summarized with brief mention about efficacy studies in each area.
The few original reports on the use of CBT which have appeared in IJP are reviewed below.
Cognitive behavior therapy in psychosis
Shriharsh et al.[45] treated 51 patients with schizophrenia or schizo-affective disorder with an average of 20 sessions of CBT spread over 10 weeks. Techniques used consisted of psycho-education, behavioral analysis, activity monitoring and scheduling, assertiveness training, relaxation, distraction techniques, systematic desensitization in vitro, exposure and response prevention, stress inoculation, skills training and cognitive restructuring. Treatment led to improved adjustment scores in Bell's Adjustment Inventory, decrease in intensity of perceived symptoms and automatic thoughts. During follow-up, gradual decline in improvement with CBT happened, but at nine months the patients were still better than they were before CBT. The paper does not give information on concomitant anti-psychotic medication which also could have had an influence on the outcome. Description of the symptoms the patients in this study had suggest that at the time of CBT most of them were in a state of post psychotic depression and were not actively psychotic. It is also not clear how many patients have had each of the various interventions listed and their effect on specific problems. Clinical significance of the improvement seen on rating scales is not given either.
In a case report on a 31-year-old man with paranoid schizophrenia, who had the delusion of being controlled, being made to laugh, cry etc. through the internet, Dugal et al.[46] report the use of verbal challenge of the delusion, arranging experiments to test patient's belief and encourage finding alternative explanations. The patient was also on 250 mg/day of clozapine. The delusion disappeared with these interventions and did not recur during the next two months.
Panic disorder
Thirty patients with panic disorder were treated by Manjula et al.[47] in two groups of 15 each. One group was treated by CBT consisting of psycho- education, applied relaxation, cognitive restructuring, interoceptive exposure and in vivo exposure. The second group was treated by what the authors call 'behavioral intervention' (BI), which included only psycho- education and applied relaxation. BT group had 15 to 20 sessions in five weeks while the BI group had eight to 10 sessions in two weeks. Although both the groups showed improvement, the CBT group was superior in the reduction of panic symptoms, avoidance behavior, safety behaviors and negative cognitions. In a large percentage of CBT patients the magnitude of change was clinically significant. The therapist herself being the assessor of improvement, inequality in the time of contact with the therapist as well as total duration of treatment are some the methodological problems that could have influenced the outcome. The BI group had only psycho-education and applied relaxation as its components whereas standard BT of panic disorder also include interoceptive exposure and in vivo exposure while in this study they are part of CBT only.
CONCLUSION
In a survey of the current scene on the use of CBT, Kuruvilla[48] evaluates the evidence base to support the use of CBT in a number of psychiatric disorders, its role in the management of certain physical disorders, innovations in the delivery of CBT and the current findings which show that CBT modulates the functioning of specific sites in the limbic and cortical regions of brain. These findings support the conclusion which Prochaska and Norcross[49] arrived at after evaluating various psychotherapies, "Cognitive Behavioral approach is the fastest growing and heavily researched psychotherapy in the cotemporary scene". It will be immensely beneficial for patients in India if psychiatrists in India make greater use of this model of therapy.
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Effect of cognitive behavior therapy on adjustment, intensity of symptoms and automatic thoughts in schizophrenia. Indian J Psychiatry 2003;45:221-8. 46. Duggal HS, Jagadheesan K, Nizamie SH. Internet delusion: Response to cognitive therapy. India J Psychiatry 2002;44:293-6. 47. Manjula M, Kumariah V, Prasadarao PS, Raghuram R. Cognitive behavior therapy in the treatment of panic disorder. Indian J Psychiatry 2009;53:108-16. 48. Kuruvilla K. Cognitive behavior therapy today. Indian J Psychol Med 2007;29:7-19. 49. Procheska J, Norcross J. Systems of Psychotherapy: A Transtheoretical Analysis. 5th ed. Pacific Grove, California: Brooks/Cole.
K. Kuruvilla Department of Psychiatry, PSG Institute of Medical Sciences and Research, Coimbatore, India 59 A review on Indian scales and inventories
S. Venkatesan
ABSTRACT
This conceptual, perspective and review paper on Indian scales and inventories begins with clarification on the historical and contemporary meanings of psychometry before linking itself to the burgeoning field of clinimetrics in their applications to the practice of clinical psychology and psychiatry. Clinimetrics is explained as a changing paradigm in the design, administration, and interpretation of quantitative tests, techniques or procedures applied to measurement of clinical variables, traits and processes. As an illustrative sample, this article assembles a bibliographic survey of about 105 out of 2582 research papers (4.07%) scanned through 51 back dated volumes covering 185 issues related to clinimetry as reviewed across a span of over fifty years (1958-2009) in the Indian Journal of Psychiatry. A content analysis of the contributions across distinct categories of mental measurements is explained before linkages are proposed for future directions along these lines.
Key words: Clinimetrics, psychometry, Indian scales and inventories, Diagnostic assessment, Behavior assessment
INTRODUCTION
For long, the discipline of 'psychometry', as a branch of psychology, dealt with the design, administration, and interpretation of quantitative tests, techniques or procedures for measurement of psychological variables, mental traits and processes like intelligence, aptitude and personality. The term literally means mental measurement. Much earlier, psychometry was viewed as one's ability to sense or read an object or another person merely by looking, holding or touching. In this historical sense, it was a form of scrying, forecasting or predicting the future-a psychic way of "seeing" something not ordinarily seeable. For example, a psychometrist could hold a watch or ring to tell about the history of that object or the person who owned it-all from what was 'recorded' in the object in the form of 'eminitions'.[1] Modern psychometry goes beyond such spiritualism, occultism and animistic beliefs. It favors mental measurement as in physical sciences. Scientific psychology re-defined itself severally until it views itself now as 'science of behavior'. The term 'behavior' describes 'observable and measurable' actions. In doing so, EL Thorndike declared that 'anything that exists; exists in some measure'.[2] Measurement is assignment of numerals to objects and events according to some rule. There are reports on an ancient Chinese practice of using mental tests to decide on promotions for civil servants.[3] Much later, Francis Galton, designated father of psychometrics, made efforts to measure intelligence using mental tests. Another tradition of 'mental measurements' is connected to psychophysics by Fechner, Weber, W Wundt, JM Cattell and C Spearman. LL Thurstone became the founder-president of Psychometric Society (1936). Spearman and Thurstone developed the theory/application of factor analysis, a statistical method used in psychometrics.[4]
MODERN PSYCHOMETRY
Psychometrics has now evolved as study on theory and technique of psychological measurements. It includes measurement of knowledge, skills, abilities, aptitudes, attitudes, intelligence, memory, creativity, adjustment and personality. The field uses measuring devices like questionnaires, schedules, rating scales, inventories, checklists and tests. It involves research related to construction of instruments and procedures for measurement, development and refinement of theoretical approaches to mental measurement. More recently, psychometry is being applied to measure beliefs, interests, motivation, academic achievement (reading, writing, spelling or arithmetic) and health-related issues. Measuring these unobservable phenomena is difficult. Attempts are made to define and quantify such phenomena. Some key concepts in psychometrics are: Reliability and validity, training prerequisites of testers, accommodating the notion of individual differences, accepting the inevitable role of measurement errors, considering cross cultural variations, issues related to fairness in testing and test use, rights/ responsibilities of test takers, testing individuals of diverse backgrounds or those under special categories. There are standards related to testing applications, responsibilities of test users, testing in clinical practice, or for program evaluation and public policy. The four basic principles in psychometric testing and test development are reliability, validity, standardization, and bias.[5]
PSYCHOMETRIC APPROACHES
Traditional psychometry relied on normative approaches to psychological assessment. For example, a person's level of anxiety is deduced from his score on a test. Then, he is compared reliably with another similar or different population of individuals. Such comparisons with a "norm group" enabled statistically based diagnostic decisions in actual practice. Standardization provided benchmarks for assessing a person against a criterion or norm. In criterion-referenced testing, the scores relate directly to the individual's competencies. For example, it may be to ascertain whether or not the person has reached a particular standard of expected behavior. Then, there are behavioral assessments which look into contemporary behaviors in individuals and are directly linked to planning/implementing programs for their remediation. In recent times, inspired by neuropsychology, idiometric approaches to assessment is gaining momentum based on a search for underlying common denominators for overt behavioral deficits. For example, ones inability to button, unbutton, pick up small objects, or hold a pencil may all be construed as a common fine motor deficit-which needs to be trained to enable all these or such related activities for that individual.[6-9]
MERITS AND DEMERITS
Properly developed psychometric tools, when used by competent and qualified individuals, have several advantages. They are relatively cheap, easy to administer, or lead to valid judgments. To put it simply, information from a good personality questionnaire, for example, might take several months of knowing and working with a person. They are likely to be of considerable cost-benefits in the long term. Whether to aid a clinical diagnosis or plan an intervention program, the expenses involved in psychometric testing is minimal compared to the costs of high-turn over, under-performance or misdiagnosis of clients. There are also perils in psychometric testing. Many tests and questionnaires are let into the market in the guise of 'psychometric instruments'. It is difficult to distinguish 'genuine' ones. These instruments are put together by people with no background in psychometrics. They have little actual utility and value for the purposes for which they are marketed. There is also a danger of their use by untrained examiners even though there is indeed, no guarantee that even trained person will at all times use them correctly. In short, psychometric tests and procedures are useful but are not necessarily universal solutions.[10]
APPLICATIONS
Psychometry has wide applications in business, industry, recruitment, personnel selection, executive coaching, teambuilding, management development and job placement, educational testing, selection, deciphering learning styles, enabling career choices, profiling individual or group behavioral assets and deficits. In recent times, it is being applied to the field of health, illness, disease, and disability behaviors. As applied to clinical medicine-especially psychiatry, psychometric tests can be viewed in two broad categories: Knowledge based and person based.[11] Tests of ability, aptitude, attainment, competence, and achievement are examples of the former, while tests of personality, clinical symptoms, mood, integrity, interests, and attitude typify the latter. Knowledge- based tests have right- wrong answers. Person-based tests differentiate different types of individuals. Within knowledge-based testing, for example, tests of clerical aptitude, computing skills, and numerical and verbal reasoning have relevance to different types of work. Speech and language therapists use tests that assess dyslexia, language impairment, and other forms of educational underachievement. Neuropsychological tests cover cognitive functions like memory and abstract thinking. Personality tests in clinical practice decipher pre- or post morbid changes in habitual, temperamental or regular patterns of behavior in an individual. A problem for all personality tests is 'lying' or 'faking good'. Much effort is put into test construction to circumvent this tendency. Today, psychometric testing has the widest applications. Most of us can expect to be tested at least once in our working lives. Because psychometrics is such a powerful tool, it is essential that it is applied responsibly.[2]
PSYCHOMETRY TO CLINIMETRY
For long, assessment in psychiatry or clinical psychology did not cover quantification. Acute but irreproducible long descriptions were used to communicate clinical observations. [12] More objective ways of clinical assessment about the severity and change in symptoms emerged later. Since then, clinical assessments placed stress on inter- clinician reliability. The assessment of clinical changes, the recent trust on psychological instruments which are valid and reliable is at the heart of clinimetrics.[13] In its quest for valid and reliable assessment, clinimetry rest its foundations on rather the clinically shaky grounds of psychometric theory. Note that developments in classical and modern psychometry took place outside of the clinical field- mainly in educational and social areas. Hence, they could not be automatically adjusted to clinical fields.[14] The inadequacies of the psychometric model in clinical setting have spurred the need for supplementation with another conceptual framework: clinimetrics!
Inadequacy of psychometry model
The inadequacies of psychometrics in clinical setting were first identified by Shapiro in 1951 and described in relation to assessment of changes in distress.[15] Sensitivity to behavior change is a requisite for clinical validity of an outcome scale. Scales may be valid and reliable. But, they may lack sensitivity. [16] This concept is important when treatment effects are small and in the setting of sub-clinical symptoms.[17,18] The psychometric model is inadequate in clinical setting owing to its search for homogeneity. Homogeneity of components, as measured by statistical tests such as Cronbach's alpha, is often seen as the most important requirement for a traditional rating scale. However, the same properties that give a scale a high score for homogeneity may obscure its ability to detect change. [19] The redundant items in a scale may increase Cronbach's alpha, but decrease its sensitivity. In psychometrics, a high correlation is often regarded as evidence that the two scales measure the same factor. However, a high correlation does not indicate similar sensitivity. When a new scale is developed with "item analysis", some of the essential variables that are sensitive to change may be either removed or not included.[18]
Several clinical scales, such as the Hamilton Depression Scale[20] was developed based on classical psychometric model. A key flaw of such instruments, developed on the basis of factor analysis or principle component analysis (in which correlation coefficients are operating by giving symptoms equal weights), is that the same score at this Scale may be the product of few very severe core symptoms (example a severely retarded depressed patient) or of several mild accessory symptoms (reflecting perhaps a subject affected by a mild form but with many symptoms and a complaining behavior)[21] An alternative model, clinimetrics is being increasingly proposed as the conceptual basis to assess clinical phenomena, diagnosis, prognosis, and therapeutics.[22,23]
Clinimetrics
The term "clinimetrics" was introduced by Alvan R. Feinstein in 1982 to indicate a domain concerned with indexes, rating scales and other expressions that are used to describe or measure symptoms, physical signs, and other distinctly clinical phenomena. The purpose of clinimetrics is to provide an intellectual home for a number of clinical phenomena. It includes the types, severity and sequence of symptoms; rate of progression of illness, severity of co-morbidity; problems of functional capacity; reasons for medical decisions; and many other aspects of daily life, such as well-being and distress.[24] A familiar example of clinimetric index is Apgar's method of scoring the newborn's condition.[25] Clinimetrics has a set of rules which govern the structure of indexes, the choice of component variables, the evaluation of consistency and validity.[26]
Clinimetrics has an advantage over classical psychometric measures in being more sensitive to symptom change. It uses a sensible method to assess symptoms based on their prevalence in those with a disorder (clinical coherence) and the importance of those symptoms for clinicians to define severity (weighting of symptoms).[22] The concept of incremental validity refers to the unique contribution or incremental increase in predictive power associated with the inclusion of a particular assessment procedure in clinical decision process. [27] A clinimetric, instead of psychometric model should guide the diagnosis in psychiatry and clinical psychology.
Clinimetrics stresses multiple points of observation during the course of illnesses by calling in fact for a substantial modification of the flat, cross- sectional approach based on singular official criteria only. A longitudinal consideration of the development of disorders may prove to be more fruitful for clinical decision making and treatment planning than a cross-sectional diagnosis.[12,17,28] An example of this approach is a recent publication on the historical analysis on course and clinical presentation of children with learning disabilities in India,[29] wherein it was demonstrated that the signs and symptoms, presentation or clinical course of the condition range from specific speech delays during preschool ages, to difficulties in pre-academic activities and writing problems during kindergarten ages, followed by mixed disturbances in reading, writing and spelling problems during early primary school years. This is followed by reported clinical presentations of behavioral difficulties during middle school ages of these children. The condition gets further disguised as problem behaviors and present either externalized as conduct disorder or internalized into emotional disturbances. Much later, during pre-adolescence or adolescence, the learning disability manifest either as severe neurotic disturbances like depression, anxiety, obsessions, compulsions and phobias or as prodromal symptoms of newly shaping passive aggressive, antisocial, or some such personality disorders.
Clinimetrics is in accordance with sequential model of treatment, which was found to be effective in psychiatry. It has clinical implications in the definition of recovery. Commonly, recovery reflects 'improvement' or the clinical distance along which the current state of the patient is compared to the pre- treatment position.[30] In this sense, recovery is expressed as categorical variable (present/absent) or as comparative category (non-recovered, slightly recovered, moderately recovered, greatly recovered). Both expressions require arbitrary cut-off points related to amount of improvement. Clinimetrics offers conceptual and methodological ground for a substantial revision of assessment parameters and for linking co-occurring syndromes. By a research viewpoint, it may pave the way for inclusion criteria and assessment tools which are more suitable for the purposes of clinical research. Rigid adherence to the psychometric model may only prevent such progress in clinical testing.
SCENE IN INDIA
Psychometry applied to psychiatry/clinical psychology (or clinimetrics) is of a recent origin in the country. These parent disciplines are themselves still struggling to establish themselves as distinct health delivery systems against the backdrop of the slush in laymen preoccupation or first preferences for magic-religious traditional treatments for psychologically affected individuals or their families. Combine this with the grim situation of growing rural-urban or rich-poor divide, gaping illiteracy, multiplicity of castes and sub-cultures, linguistic plurality, religious jingoism and gender differences in the larger populations-all of which contribute to the scenario of poor understanding of westernized paper pencil tests, or acceptance of psychometry based clinical testing. Despite these limitations and challenges, the field of clinimetrics has witnessed a periodic although unsteady or patchy growth in mental health practice in the country. Such research developments have been intermittently published in some applied psychology and psychiatry journals. In the following, publications related to clinimetry in Indian Journal of Psychiatry (IJP) between October-December, 1958 and July- September, 2009 are summarized and discussed.
CONTRIBUTIONS BY INDIAN JOURNAL OF PSYCHIATRY
The IJP is an official quarterly publication of Indian Psychiatric Society. It publishes peer-reviewed original work related to psychiatry. For purpose of this review, 51 back dated volumes covering 185 issues (excluding supplements, editorials, guest editorials, letters to editor, presidential addresses, book reviews, award papers, or reports, theoretical reviews, etc) were individually scanned for a complete and comprehensive bibliographic search on original articles, research papers and submissions related to clinimetrics. The term 'clinimetric' as operationally defined in this paper refers to any or all those research articles which are directly worked on clinical populations related to test construction, validation, field-try out, standardization, application and/or their translations. A complete review of clinimetric contributions in IJP reveled 105 research articles in about 2582 research papers (4.07 %) surveyed across a span of over fifty years (1958-2009) [Table 1]. A further content analysis of such clinimetric contributions in the journal showed that the reviewed scientific papers broadly fell under four distinct categories of mental measurements:
Personality
Research articles pertaining to personality measures and studies have been amongst one of the earliest concerns in modern Indian psychiatry as evidenced by the use of projective techniques, such as, Rorschach Inkblots for various clinical groups including schizophrenics,[31,32] murderers,[33] or other psychiatric cases.[34] Another projective technique, namely Draw a Person Test was also tried on homosexuals in another related study.[35]
Simultaneously, early research interest was on development/use of other personality measures like inventories,[36] especially Eysenck,[37,38] Maudsley,[39,40] MMPI[41] or in mutual comparisons with one another.[42] Later, there was a brief interest in getting authenticated translated versions of these inventories in vernacular[43-46] or studying specific sub aspects of personality types or profiles in relation to specific psychiatric manifestations.[47-49] In this connection, measurement of personality traits- either psychoticism-neuroticism,[50] authoritarianism[51] or in consonance with particular psychiatric disturbances was some of the beginning concerns in this field.[52,53] During the period surveyed in this study, there were in only 6 inventories studied by contributors to the IJP in the area of personality in psychiatry [Table 2].
Cognition
In the area of measurement of cognition, various aspects have caught the early interest of researchers. The 'Bender Gestalt Test; was tried to discriminate organic/functional disturbances in psychiatric patients.[54-56] Later, the study of thought disturbances in major mental disorders was focused,[57] along with difficulties in recognition,[58] and memory.[59] Almost after a decade and half later, interest in cognitive research underlying mental disorders got revived with the belated arrival of neuropsychology as a discipline. [60- 63] Although not adequately knit, these interests are continuing sporadically and disjointedly until recently.[64-66] During the period surveyed, there were in all 5 tests worked upon by contributors in the area of cognition [Table 2].
Diagnostic
Diagnostic psychiatry has always waited for psychometric tools to be the look alike of pathology tests, to aid in screening, identification of quick diagnosis of various clinical conditions. It has always wanted an aide to objectively and efficiently help in diagnostic decision making. In this pursuit, after the era on projective techniques, one can distinctly see several paper pencil tests or clinical scales emerging in their place, such as, Middlesex Hospital Questionnaire,[67-70]
PGI Health Questionnaire,[71,72] Beck Depression Inventory,[73] General Health Questionnaire,[74-76] Goldberg General Health Questionnaire,[77] Depression-Happiness Scale,[78] Hamilton Depression Scale.[79] The purpose and expectation from these tests/measures was to tell the diagnostician whether a given patient had a particular disorder or not based on a numerical score or cut off point. No wonder, this expectation from psychometric tests was to parallel pathology tests in medicine to enable the physician to decide whether a patient has a particular disease is reflected in the highest number of 16 such instruments researched by contributors to IJP [Table 2].
Others
In recent times, clinimetrics as applied to Indian psychiatry appears to be moving away from its rather rigid medical model. It is beginning to appreciate the importance of attitudes, opinions, and similar other soft skills in patient care/ improvement. This is evidenced by studies published in IJP related to families, their perceptions,[80] interaction patterns,[81] illness behavior,[82,83] social functioning,[84] burden,[85,86] coping strategies,[87,88] handling patterns,[89] social supports,[90] attitudinal variations,[91-95] stressful life events,[96-98] quality of life,[99,100] etc. These recent concerns on psychometric instruments related to social dimensions of psychiatry are reflected as research works on 12 scales by contributor to this journal [Table 2]. In terms of life span perspective, there was one paper on clinical psychometry applied to pediatric psychiatry of infantile autism,[101] another on infant intelligence scales,[102] childhood psychopathology[103] or their temperamental characteristics. [104] There were no scales related to adolescent psychiatry and there was one paper on scale for old age psychiatry.[105]
CRITICAL REVIEW
From the foregoing, it is evident that clinimetrics has received low priority in the pages of IJP over the years. There are many areas, problems and issues in contemporary mental health practice wherein inter-disciplinary/multi- disciplinary inputs are needed. An earlier lament for greater objectivity in psychiatric research is true even today.[106] One can wish away this shortcoming by defending that test development appropriately falls in the domain of a sibling discipline in clinical psychology; or that psycho-social issues in psychiatry research vests with psychiatric social work. But, this defense is untenable if one wishes to rise above biological psychiatry into community/social psychiatry, industrial psychiatry, preventive mental health, school mental health, etc. With a new breed of changed social scenario of ready made two- minute mendicants and missionaries preaching spiritual peace or tranquility and what with increasing life style disorders, transitional difficulties, culture bound recessions, changed systems of education, IT enabled and materialistic living bereft of genuine spiritual musings, the contemporar y social scene is fertile for development of psychopathology.[107,108]
The review shows neglect on mental health issues related to old age and elderly, women and domestic violence, transgender, and disabled. Take the example of an extensive bibliographical research in the field of mental retardation undertaken by Indian investigators on populations within the country and published in over 100 national journals spanning sixty years.[109] It was found that in the surveyed period, there were no more than 1095 (68.91%) research articles on mental retardation, 15 (0.94%) papers on autism, and only 4 papers (0.24%) on learning disabilities. Among many other findings, it was seen that the IJP stood at seventh rank (3.84%) after 'Indian Journal of Pediatrics' (19.63%) and 'Indian Pediatrics' (12.15%) in terms of number of publications on mental retardation. Apart from commenting on the quality or repetitiveness of studied areas in the undertaken research, this study concluded that disability is the most neglected area of study by all professionals. There were hardly tools/scales on early intervention, prevention, inclusive education, consumer behaviors, professional conduct, changing perspectives/definitions of disability, mainstreaming, community based initiatives, access audit, empowerment issues, community impact evaluations, historical analysis, cost-benefit studies, etc. Clinimetric devices need to be developed and standardized in several of these unaddressed areas.
Another line of needed research is periodic revalidation of antique tests. Ours is probably the only country where testers continue to use decade old versions of tests, inventories and/ or scales to make standard comparisons of individuals in the present 'super computer and information age' with norms and manuals prepared in the west or those prepared in 'before-man-in-the- moon' era of our country. In most instances, there are no adaptable or adjustable norms for mentally ill, those with special needs, minority groups, the rural, under privileged, neglected, discriminated and marginalized. Though one may fault normative approaches and attempted comparisons between individuals, for purpose of certification and tentative impressions on diagnosis, periodic up grading of such norms is indispensable. Therefore, cues may be taken from papers addressed to reporting revalidated norms for popular tests, such as, Bender Gestalt Visuo Motor Test,[110] Binet Kamat Intelligence Scale,[111] Gessell Drawing Test,[112] Seguin Form Board,[113,114] Play Activity Checklist for Mental Retardation,[115] Mathematics Anxiety Rating Scale,[116] Parental Attitude Scale[117] etc.
Diagnostic testing and statement of deviations or delay in a given individual from the so called 'normal' does not complete the job of a clinimetrician. In fact, this is just the beginning of identification for certification. However, the real work would be to plan intervention programs. There is a need for structured, systematic and standardized intervention packages for persons with mental ill health problems. Such packages need to be comprehensive, flexible, field tested, viable, functional, objective, observable and measurable-all and at the same time Indian at heart. An attempted answer for this problem was the development and standardization of 'Behavior Assessment Scales for Children with Mental Retardation',[118] the 'Activity Checklist for Preschool Children with Developmental Disabilities'[119] now the 'Assessment of Kids with Special Handicaps in Arithmetic and Reading- Writing Activities'.[120] More such intervention based ready-made/easy-to- use Indian scales are required to meet exclusive needs of kids with multiple handicaps, severe-profoundly affected individuals and/or their families. And, what's more! This entire package must come in regional languages. This is the understanding and logic behind the now popular 'Toy Kit for Kids with Developmental Disabilities'[121] made available in English and Kannada. Things are definitely changing. Take the instance of the claimed phenomenon of increase in numbers of autism and learning disabilities (a terrible term word for kids with average intelligence and a cruel curriculum imposed on them). Clinical psychometry has a far greater role and responsibility towards several thousands of such children out there in every school-more than simply issuing a certificate or report of learning disability!
Formal testing devices are needed to explore consumer demand for services in the area of mental health, problems and issues related to management of mentally ill persons in home settings. There are differential self and other perceptions on or about affected individuals, their caregivers, siblings and family which need to be explored in the local context. In this era of information age, contemporary clinimetrics needs to re-adapt, shed ancient attitudes and ways of testing, blend with available gadgetry. A sample of this kind is ongoing work on development and standardization of a software program and expert system to enable computerized testing, diagnostic decision making apart from intervention planning and programming for individual children with developmental disabilities.[122]
Online assessments, chat rooms, e-based discussions, consultations and therapeutic self help groups are becoming increasingly popular even in our country. A recent paper on content analysis of transcripts derived from data mining of 3436 email exchanges in a organized internet group on of netizens revealed that many parents are lost in the quagmire of information overload as they discuss/seek more than 238 types of treatment for children on the autism spectrum.[123] Unless the contemporary practitioners become computer savvy, there is likelihood of their being left behind in the ongoing race between man and machine. Further, the calamitous outcome of over involvement of contemporary human living with machines in preference for human interactions have also resulted in loss of social niceties, emotive skills, person to person exchange competencies, and the like-all of which is an important material for investigation in the field of positive mental health. This has been demonstrated in another paper on the 24- hour activity log of typical kids on the autism spectrum and those with developmental disabilities which reported the amount of time spent per day on needed constructive activities like 'home teaching' (4.32%) or 'playing with peers' (4.12%) are meager.[124] It is one thing to innovate, create, design or develop models or services for special populations of individuals in the country. It is quite another thing to disseminate, distribute and dispense them for the ultimate benefit of end users.
EPILOGUE
There are a wide range of psychometric tests as there are psychometric examiners-many of who may be untrained, inexperienced and confused too. The application of psychometrics to psychiatric practice is called clinimetrics. Clinimetric tests are useful for collecting huge mass of data or for certain routine clinical tasks. The test findings must be viewed only as a kind of random sampling of the individual/s behavior obtained under controlled conditions in terms of their responses to questions and reactions to various situations. The score of an adequately standardized test must be only taken as an indicative index of the psychological variable being measured. This field may be viewed as analogous to that of laboratory technicians in the field of medicine. In dynamic clinical work, traditional psychometry would be just as effective as the technicians report in the hands of a physician. No physician would end up making a diagnosis based on a laboratory report alone. Similarly, no psychiatric diagnostician must make or take a decision based on psychometric findings alone to the exclusion of other adjunct methods like case history, direct clinical observation, individual or family interview, mental status examination, family history, etc.
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Analysis of rorschach test of 250 cases of schizophrenia. Indian J Psychiatry 1971;13:248. 33. Sethi BB, Gupta SC, Raj AS, Nathawat SS. Rorschach as a measure of psychopathology in murder. Indian J Psychiatry 1971;13:243. 34. Ardhapurkar IB, Doongaji DR. A Selective study of rorschach records-209 cases. Indian J Psychiatry 1965;7:287. 35. Sreedhar KP, Rao VA. Draw A person test in two male homosexuals. Indian J Psychiatry 1973;15:402. 36. Gupta SC. A Personality Inventory. Indian J Psychiatry 1966;8:1:4. 37. Verghese A. Eysenck personality n scores in different diseases. Indian J Psychiatry 1969;11:71-4. 38. Verghese, A, Sundar, P, Rao, PSS, Abraham, A. The E.P.I. scores in a group of candidates for admission into a medical college. Indian J Psychiatry 1971;13:107. 39. Jain IS, Prasad M, Gupta SC, Singh K. Evaluation of the personality of the blind through maudsley personality inventory. Indian J Psychiatry 1972;14:333. 40. Sreedhar CP, Chinnian RR, Rao VA. The Maudsley personality inventory scores in a group of psychiatric patients. Indian J Psychiatry 1974;16:244. 41. Deshmukh DK, Eswaran S, Nagesh RP, Mahajan S. A comparative study of MMPI Profiles of Psychiatric Pgs V/s Medical Pgs. Indian J Psychiatry 1980;22:298. 42. Gupta AK, Sethi BB, Gupta SC. EPI and 16 PF Observations in smokers. Indian J Psychiatry 1976;18:252. 43. Abraham A, Rao PS, Verghese A. Standardization of vernacular translations of the eysenck personality inventory. Indian J Psychiatry 1977;19:60. 44. Verma SK, Wig NN. Standardization of a neuroticism questionnaire in hindi. Indian J Psychiatry 1977;19:1:67. 45. Arora M, Varma VK. A Psychoticism Scale in Hindi: II Standardization. Indian J Psychiatry 1980;22:230. 46. Arora M, Varma VK. A Psychoticism scale in hindi: I. Construction and initial tryouts. Indian J Psychiatry 1980;22:225. 47. Raju GG, Krishnaswamy S, Verghese A, Mahadevappa H. Usefulness of bortner rating scale in the measurement of type A behavior pattern. Indian J Psychiatry 1987;29:4:373. 48. Sahasi G, Chawla HM, Bhushan B, Kacker C. Eysencks personality questionnaire scores of heroin addicts in india. Indian J Psychiatry 1990;32:1:25. 49. Kannapiran T, Haroon AE, Vivekanandan S, Arnagiri S. Personality profiles of self immolators. Indian J Psychiatry 1997;39:37-40. 50. Pershad D, Verma SK, Wig NN, Wahi PL. Measures of neuroticism and prediction of psychiatric disturbances in patients with cardiac surgery. Indian J Psychiatry 1972;14:130. 51. Varma VK, Akhtar S, Kaushal P, Vasudeva P, Kulhara PN. Measurement of authoritarian traits in india. Indian J Psychiatry 1973;15:156. 52. Abraham A, Verghese A. The Association between EPI scores and academic achievement among medical students. Indian J Psychiatry 1973;15:354. 53. Wig NN, Pershad D, Verma SK, Menon DK. Usefulness of certain personality tests for prediction of psychiatric disturbances follow in tubal ligation. Indian J Psychiatry 1977;19:55. 54. Dube KS. The Bender Gestalt Test. Indian J Psychiatry 1965;7:47. 55. Bagadia VN, Doshi J, Pradhan PV, Shah IP. A study of the bender gestalt test in 222 adult psychiatric cases. Indian J Psychiatry 1975;17:33. 56. Pershad D, Verma SK, Malhotra S, Prabhakar S. Screening of organic brain dysfunction. Indian J Psychiatry 1984;26:349. 57. Singh MV. A psychometric approach to schizophrenic thought disorders. Indian J Psychiatry 1971;13:113. 58. Pershad D, Wig NN. A recognition test for clinical use. Indian J Psychiatry 1976;18:1. 59. Pershad D, Wig NN. Reliability and validity of a new battery of memory tests. Indian J Psychiatry 1978;20:76. 60. Nizamie A, Nizamie SH, Shukla TR. Performance on Luria-Nebraska neuropsychological battery in schizophrenic patients. Indian J Psychiatry 1992;34:321. 61. James MX, Nizamie A, Nizamie SH. Comparative study of clinical effectiveness of luria nebraska neuropsychological battery, EEG and CT scan in brain damaged patients. Indian J Psychiatry 1997;39:49-53. 62. Mishra BP, Gupta V, Mahajan R, Narang RL. Pattern performance of schizophrenic patients on Luria-Nebraska Neuro-psychological battery. Indian J Psychiatry 2002;44:47. 63. Mishra BP, Mahajan R, Dhanuka A, Narang RL. Neuro-psychological profile of epilepsy on luria-nebraska neuropsychological battery. Indian J Psychiatry 2002;44:53. 64. Andrade C, Madhavan AP, Kishore ML. Testing Logical memory using a complex passage: Development and standardization of new test. Indian J Psychiatry 2001;43:3:252 65. Kohli A, Kaur M. Wisconsin Card Sorting Test: Normative data and experience. Indian J Psychiatry 2006;4:181. 66. Vahia VN, Bhojraj T, Creado DA. Neuro-cognitive deficits in HIV-positive patients-two case reports: Revising current AANTF, guidelines in view of recent revelation of new neuro cognitive symptoms. Indian J Psychiatry 2006;48:193. 67. Prabhu GG. Clinical utility of The Middlesex Hospital Questionnaire in India. Indian J Psychiatry 1972;14:127. 68. Srivastava ON, Bhat VK. The Middlesex Hospital Questionnaire (M.H.Q.) standardization on a hindi version. Indian J Psychiatry 1974;16:283. 69. Somasundaram O, Mathurubootham N. Standardization of tamil version of Middlesex Hospital Questionnaire. Indian J Psychiatry 1979;21:163. 70. Gada MT. Standardization of gujarati version of Middlesex Hospital Questionnaire. Indian J Psychiatry 1981;23:146. 71. Wig NN, Verma SK. PGI Health Questionnaire N-1: A Simple Neuroticism Scale in India, Indian J Psychiatry 1973; 15:1:80. 72. Wig NN, Verma SK. PGI Health Questionnaire-a simple neuroticism scale in india. Indian J Psychiatry 1993;15:80-8. 73. Ajmany S, Nandi DN. Adaptation of AT. Beck et al.'s An inventory for measuring depression. Indian J Psychiatry 1973;15:4:391. 74. Shamasunder C, Sriram TG, Muraliraj SG, Shanmugham V. Validity of a short 5-item version of the General Health Questionnaire (GHQ). Indian J Psychiatry 1986;28:3:217. 75. Jacob KS, Bhugra D, Mann AH. General Health Questionnaire-12: Psychiatric properties and factor structure among indian women living in the united kingdom. Indian J Psychiatry 1997;39:196-9. 76. Pothen AK, Philip K, Braganza D, Joseph A, Jacob KS. The validation of the tamil version of the 12 item General Health Questionnaire. Indian J Psychiatry 1999;41:217. 77. Gautam S, Nijhawan M, Kamal P. Standardization of hindi version of Goldbergs general Health Questionnaire. Indian J Psychiatry 1987;29:63. 78. Kishore TM, Pal SE. The depression-happiness scale and quality of life in patients with remitted depression. Indian J Psychiatry 2003;45:40. 79. Prasad MK, Udupa K, Kishore KR, Thirthalli J, Sathyaprabha TN, Gangadhar BN. Inter-rater reliability of hamilton depression rating scale using video-recorded interviews-focus on rater-blinding. Indian J Psychiatry 2009;51:191. 80. Gopinath PS, Chaturvedi SK. Measurement of Distressful Psychotic Symptoms Perceived by the Family: Preliminary Findings, Indian J Psychiatry 1986; 28:4:343. 81. Bhatti R, Ageira, B Validation of Family Interaction Patterns Scale Indian J Psychiatry 1986;28, 3, 211. 82. Varma VK, Malhotra A, Chaturvedi SK. Illness Behavior Questionnaire (IBQ): Translation And Adaptation In India, Indian J Psychiatry 1986; 28:1:41. 83. Chaturvedi SK, Bhandari S, Rao S. Illness behavior assessment of psychiatric patients with somatic presentation, Indian J Psychiatry 1988; 30:2:205. 84. Padmavati R, Thara R, Srinivasan L, Kumar S. SCARF Social Functioning Index. Indian J Psychiatry 1995;37:161-4. 85. Roychaudhuri J, Modal D, Boral A, Bhattacharya D. Family burden among long term psychiatric patients. Indian J Psychiatry 1995;37:102-9. 86. Thara R, Padmavathi R, Kumar S, Srinivasan L. Burden assessment schedule: Instrument to assess burden of caregivers of chronic mentally Ill. Indian J Psychiatry 1998;40:21-9. 87. Rao K, Subbakrishna DK, Prabhu GG. Development of a coping checklist-a preliminary report. Indian J Psychiatry 1989;31:2:128. 88. Chandrasekharan R, Chitralekha V. Patterns and determinants of coping behavior of wives of alcoholics. Indian J Psychiatry 1998;40:30-4. 89. Malhotra S. A Parental Handling Questionnaire. Indian J Psychiatry 1990;3:265. 90. Kulhara P, Avasthi A, Gupta N, Das MK, Nehra R, Rao AS, et al. Life Events and Social Supports in Married Schizophrenics. Indian J Psychiatry 1998;40:376-82. 91. Das K, Kulhara P. Maternal Attitude and Maternal Adjustment: Development of a Scale for use in India setting. Indian J Psychiatry 1991;33:187. 92. Avasthi AK, Varma VK, Nehra R, Das K. Construction and standardization of a sex knowledge and attitude questionnaire (SKAQ) in simple hindi, for north indian population. Indian J Psychiatry 1992;34:24. 93. Basu D, Malhotra A, Varma VK, Malhotra R. Development of scale to assess attitudes towards drinking and alcoholism. Indian J Psychiatry 1998;40:158-64. 94. Satija YK, Advani GB, Nathawat SS. Influence of Stressful Life Events and Coping Strategies in Depression Indian J Psychiatry 1998,40:2:165-171. 95. Venugopal D, Ranjith G, Issac MK. A questionnaire survey of psychiatrists attitudes towards genetic counseling. Indian J Psychiatry 2000;42:163. 96. Chandrashekar CR, Reddy V, Issac MK. Life events and somatoform disorders. Indian J Psychiatry 1997;39:166-72. 97. Kumar PN, Das J, Bagchi DJ, Pal HR. A comparative study of life events in depression and mania. Indian J Psychiatry 1998;40:370-5. 98. Raju MS, Srivastava K, Chaudhury S, Salujha SK. Quantification of stressful life events in service personnel. Indian J Psychiatry 2001;43:213. 99. Lobana A, Mattoo SK, Basu D, Gupta N. Convergent validity of quality of life interview (QOLI) in indian setting: Preliminary findings. Indian J Psychiatry 2002;44:118. 100. Chaudhury S, Srivastava K, Kamaraju MS, Salujha SK. A Life Events Scale for Armed Forces Personnel. Indian J Psychiatry 2006;48:165. 101. Sreedhar KP, Rao VA. Draw a person test in two male homosexuals. Indian J Psychiatry 1973;15:402. 102. Koshy V, Sharma SD. Standardization of the cattells infant intelligence scale in india. Indian J Psychiatry 1984;26:327. 103. Malhotra S, Varma VK, Malhotra A. Childhood psychopathology measurement schedule: Development and standardization. Indian J Psychiatry 1988;30:4:325. 104. Narang RL, Gupta R, Mishra BP, Mahajan R. Temperamental characteristics and psychopathology among children of alcoholics. Indian J Psychiatry 1997;39:226-31. 105. Rao VA. Assessment scales in old age. Indian J Psychiatry 1999;41:388. 106. Prabhu GG. Objectivity in psychiatric research-A review. Indian J Psychiatry 1967;9:119. 107. Venkatesan S. Psychological assessment of individuals with mental retardation: Some perspectives and problems. Creative Psychol 1991;3:65-75. 108. Venkatesan S, Choudhury S. Psychodiagnostic assessment of rural children with mental handicaps in india: Some problems and issues. Creative Psychol 1995;7:1-9. 109. Venkatesan S, Vepuri VG. Mental retardation in india: A bibliography. New Delhi: Concept Publishers; 1995. 110. Venkatesan S. Bender gestalt visuo motor test as measure of intelligence in mentally handicapped individuals. Indian J Clin Psychol 1991;18:7-9. 111. Venkatesan S. Reappraisal of bombay-karnatak version of binet simon intelligence scales (1964). Indian J Clin Psychol 2002;29:72-8. 112. Venkatesan S. Extension and validation of gessells drawing test of intelligence in a group of children with communication disorders. Indian J Clin Psychol 2002;29:173-7. 113. Venkatesan S. Revalidation of seguin form board test for indian children. Indian J Appl Psychol 1998;35:38-42. 114. Venkatesan S, Basavarajappa Divya M. Seguin form board test: Field try out on a modified procedure of test administration. Indian J Appl Psychol 2007;44:1-5. 115. Khoshali AK, Venkatesan S. Play behaviors in children with mental retardation. Psychol Stud 2007;52:90-4. 116. Karimi A, Venkatesan S. Development and preliminary validation of mathematics anxiety symptoms in high school students. Asian J Dev Matters 2009;3:176-80. 117. Venkatesan S. Parental attitude scale on early childhood education (PAS-PSE) Agra: Vedant Publications; 2002. 118. Peshawaria R, Venkatesan S. Behavior Assessment Scales for Indian Children with Mental Retardation. Secunderabad: National Institute for the Mentally Handicapped, 1992. 119. Venkatesan S. Children with developmental disabilities: A training guide for parents, teachers and caregivers. New Delhi: Sage (India) Publications; 2004. 120. Venkatesan S. Assessment of kids with special handicaps in arithmetic and reading- writing activities' (AKSHARA) (Venkatesan, 2009). Mysore: AIISH, 2009. 121. Venkatesan S. Toy kit for kids with developmental disabilities: User manual. Mysore: AIISH, 2004. 122. Venkatesan S. Development and standardization of computer assisted software on behavioral assessment and learning activities for kids with communication disorders (BALAK-CD). Mysore: AIISH, 2009. 123. Venkatesan S, Purusotham P. A profile of etiological and therapeutic searches by netizen parents/caregivers of children on the autism spectrum. JAIISH 2008;27:89-94. 124. Venkatesan S. Activity log of preschool children with developmental disabilities and autism spectrum disorders. Asia Pacific Dis Rehab J 2005; 16:68-76.
S. Venkatesan Department of Clinical Psychology All India Institute of Speech and Hearing Mysore - 570 006, Karnataka, India 60 Liaison psychiatry
S. R. Parkar, N. S. Sawant
ABSTRACT
Liaison in Psychiatry refers to the branch of Psychiatry involving assessment and treatment in the general hospital of referred patients, like in the casualty, or patients of deliberate self farm. The Indian scene also reveals major reference from medicine, surgery, surgical super specialty and orthopedics with psychiatric disorders like anxiety, depression and / or organic brain syndromes seen in about 40 to 50 % of the medical or surgical patients. Though the Indian published data is limited, most tertiary hospitals in India carry out liaison work with various departments like Neurology, Organ transplant, Intensive Care Units and Cosmetic Surgery, so as to give comprehensive health services to patients. Liaison in Psychiatry has thus brought the emphasis on the teaching of psycho-social aspects of medicine and also increased research possibilities.
Key words: Liaison psychiatry, GHPU, ???
INTRODUCTION
Mental health consultation is the need of the hour and has been emphasized on since time immemorial.[1] In the beginning, medical professionals reacted unfavorably to the admission of psychiatric patients in general hospitals. However with recognition of organicity and superimposed psychological reaction to medical illness in medical and surgical departments, psychiatry was appreciated and eventually integrated.[2] The rapid growth of general hospital psychiatric units all over the world has provided impetus to consultation-liaison work carried out by the psychiatrists. Consultation liaison psychiatry (CLP) was generally limited to the diagnostic, research and therapeutic activity in the non psychiatric departments of the general hospital. It is synonymous to liaison psychiatry (psychiatric dictionary, Oxford 1970). The mainstay CLP reports are to recommend the referrer basic logical clinical findings, appropriate treatment and follow-up programs. In addition, other objectives are educational, ethical and medico-legal.
Though general hospital psychiatry was considered to come to light as a result of the lack of sufficient funds to initiate new lunatic asylums, today it is acknowledged as a major part of the public health system that takes care of mental health problems of a large population. Today, Liaison Psychiatry has acquired the status of a subspecialty within psychiatry and this has helped shift psychiatry from mental hospitals to a general hospital setting. This has also increased referrals from the non-psychiatric departments and given the psychiatrist an opportunity to directly deal with the physically ill.[3] In general, there is no specific philosophy or particular clinical context being identified in Liaison Psychiatry, at present, in India.
Referral types
Several researchers have found a lower referral rate in the Indian counterparts as compared to the western figures. Jindal et al.(1980) found a poor referral rate in their study as compared to other studies conducted in India.[4] The in-patient referral rate in their study was 0.15%, as compared to 1.4%. in the study by Prabhakaran (1968) and 0.66% in the study by Parekh et al. (1968).[4-6] Chatterjee and Kutty (1977) reported a referral rate of 2.64% among the out-patients as compared to 0.06% by Jindal et al.[7,4] Most studies quote about 60% of referrals from general medicine and 14% from surgery and surgical super-specialties.[4-6]
There is also a paucity of data concerning psychiatric emergency referral in the Indian setting. Most of the available studies pertain to the routine inpatient referral.
Though psychiatric services are available in almost all teaching general hospitals in India, little is known as to why the psychiatrist is called in emergency situations and what is the magnitude of the problem. Kelkar et al. (1982) found suicidal attempt (13%), excitement and violence (10%) and altered sensorium (9%) which constituted 32% of the total emergency referrals.[8] In the study by Gautam (1978) a vast majority (88%) of the sample of patients who presented with somatic symptoms were neurotics.[9]
General hospital psychiatry units
General hospital psychiatry units have provided increased opportunities for interaction between psychiatrists and other medical specialists, making consultation-Liaison Psychiatry more meaningful .The establishment of General Hospital Psychiatry Units (GHPU) proved an impetus for Indian studies on psychiatric morbidity in medical-surgical inpatients.[10] Among the first units of this nature were those of R. G. Kar Medical College and Hospital, Calcutta and Grant Medical College and J.J . Group of Hospitals, Bombay, started in 1933 and 1938 respectively. By 1970, about 90 psychiatric clinics were operative in India (Directory of Mental Health Services in India, 1970). The spectrum of psychiatric case material seen in general hospital psychiatry units is much wider than seen in mental hospitals. Unlike mental hospitals, where the clinical material is predominantly psychosis, in a general hospital psychiatry unit there is a wide range of clinical problems including psychoses, neuroses, personality disorders, drug dependence and organic brain disorders.[11-13] Referral from inpatient services offers additional area for study in psychosomatic illness.[14] Malhotra S (1984), in her study, found that it was not simply the presence of abnormal behavior that prompted psychiatric consultation, but other reasons like organic illness insufficient to explain symptoms.[3] The trends worth noting were, however, a low representation of personality disorders and drug/alcohol dependence in their study with a uniformly low representation of psychosomatic disorder also. The possible explanations for this may be the focus on classical psychiatric disorders and not the personality disorders which are prevalent currently, due to various classification systems like Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).
A high prevalence of psychiatric morbidity amongst general hospital OPD patients was reported in some studies in India, (36%) Krishnamurthy S et al. (1981)and (10.4%) by Sriram et al. (1987).[15,16] R.S. Murthy (1998), in his editorial, stated that the developments in the twentieth century have dramatically changed concepts of mental healthcare as a result of new knowledge and has seen a shift from mental illness to mental health.[17]
Bhogale et al. (2000) found that 47.57% of indoor referrals and 62.75% of outdoor referrals had unexplained physical symptoms.[18] This group also included those patients who had co-existing physical illness but symptoms were disproportionate to the physical condition. Analysis of final diagnoses in this study discovered that a large majority of the patients had neurotic, stress related, somatoform disorders (indoor 36.76% and outdoor 52.29%) followed by mood disorders (indoor 21.08% and outdoor 18.95%). The authors suggest that more interaction and dialogue between psychiatric team and referring physician is a need; their study highlighted that types of patients referred in multi specialty hospitals are vastly different and the present post-graduate training in psychiatry and psychology was inadequate in this area.[18]
Diverse research studies
There are some diverse studies which have been reported in the Indian Journal Psychiatry. They are infrequent from those that follow diagnostic profile. They are worth noting in the Indian context. In the general hospital, in the psychiatric clinic, N. N. Wig (1968) reported cases of post vasectomy syndrome; the common pattern being that of a chronic and disabling neurasthenic hypochondriac state. [19] However, till date, these aspects have not been researched in Indian Psychiatry. There is some research documentation from army set up in IJP. A survey, by Major R. S. Mathur (1977,) of 638 soldiers hospitalized for physical illnesses or trauma in a military hospital has revealed psychiatric morbidity in 34.5% of them, manifesting mainly in states of depression (47.9%) and anxiety (40.9%).[20] Psycho- neuroses without obvious depression or anxiety formed 11.4%. The subjects who showed psychiatric morbidity with their somatic illnesses had a longer hospitalization period than the others. Positive correlation of psychiatric morbidity in physical diseases has been noticed with certain diagnostic categories, literacy level and certain states of residence; and no correlation has been seen with age, marital status, and length of service or rank of the subjects. In some cases of intra-cranial space occupying lesions, infections and cerebral seizures, who either presented as psychiatric problem or developed mental symptom, an attempt was` made to discuss the pathophysiology of psychiatric symptoms in organic brain diseases.[21] Dash and Dash (1979) found that despite advice of termination of pregnancy in certain vulnerable patients on psychiatric grounds, only 56 per cent of them accepted medical advice.[22] These patients were better educated, hailed from urban areas and belonged to higher strata of society than those who rejected such an advice. Comparison of diagnoses in the 1967 and 1977 groups showed marked differences with decrease in the epilepsy and organic brain syndromes due to the development of a neurology department.[23]
The proportionate number of schizophrenics in the clinic population has more than doubled over the 10-year period. This is possibly because of better awareness. Indian Research on liaison work is mostly with cardiology, dermatology, orthopedics, gynecology, medicine, gastroenterology and ophthalmology. Thus there is a great scope for combined service and training programs with other specialties like internal medicine, pediatrics, neurology, obstetrics and gynecology. In fact, there is hardly any clinical specialty which is not related to psychiatry or with which psychiatry cannot combine, to organize a program.
New avenues are coming up daily with the introduction of new services where psychiatric aspects are of great importance in a general hospital. Cardiac surgery, epilepsy surgery, cosmetic surgery, dialysis units, kidney transplants, intensive care units and family planning services are some of the examples in this growing field. Chandra has done extensive work in the area of women's mental health in general and specifically the area of the interface between psychiatry and women's reproductive and sexual health with far reaching clinical and social consequences.[24] Comparatively, a lot of work has been documented in the area of deliberate self harm and suicide in Indian set-up. One critical finding by R.K. Chadda and S. Shome (1996) is that psychiatric consultation services are not sufficiently utilized by a large number of clinicians.[25] Most of them felt the need to improve upon undergraduate medical education in psychiatry in India as well as a desire to have consultation - liaison psychiatric units in India. In an interesting study by P. Gopala Sarma (2000), on patients attending general hospital psychiatry out- patient (OP), the cost of one visit was Rs. 201. The management's contribution to the total expenditure was 68% and patients' 32%. Salaries accounted for the maximum - 48%. This was followed by loss of earnings -17%. Drugs accounted for less than 10%.[26]
Liaison Psychiatry has brought the emphasis on the teaching of psychosocial aspects of medicine in diverse manners like bedside interviews, interdepartmental case conferences. Research possibilities are unlimited. There are many examples of psycho geriatric clinics and memory clinics in operation in general hospital psychiatry set-ups in India and data from these set-ups will be useful in guiding these special services. Numerous studies on the psychosocial aspects of physical illness and new medical and surgical procedures, such as chronic hemodialysis, open heart surgery, organ transplantation doctor-patient relationship; stress and coping strategies; psychological antecedents of illness and many other relevant clinical problems have been carried out.[3] In all probability, an even more important need of research in the area of liaison psychiatry is to put together a "client profile" and develop tailor made services in the most advantageous way. It is acknowledged that these services are acceptable to people and there by will be able to reduce stigma related to Psychiatry. In future, however, there is a need to look at cost effective planning of these services as well as the role of socio-cultural and biological parameters in liaison psychiatry.
REFERENCES 1. Kirpal Singh. Mental Health Consultation. Indian J Psychiatry 1965;4:215-6. 2. Wig NN. General Hospital psychiatric unit- right time for evaluation. Indian J Psychiatry 1978;20:1-9. 3. Malhotra S. Liaison Psychiatry In General Hospitals. Indian J Psychiatry 1984;26:264-73. 4. Jindal RC, Hemrajani D K. A study of psychiatric referrals in a general hospital. Indian J Psychiatry 1980;22:108-10. 5. Prabhakaran M. In patient psychiatric referrals in a general hospital. Indian J Psychiatry 1968;10:73. 6. Parekh HC , Desmukh BD, Bagadia VN, Vahia NS. Analysis of Indoor Psychiatric referrals in a General Hospital. Indian J Psychiatry 1968;10:81. 7. Chatterjee SB, Kutty PR. A study of psychiatric referrals in military practice in India. Indian J Psychiatry 1977;19:32. 8. Kelkar DK, Chaturvedi SK, Malhotra S. A study of emergency psychiatric referrals in a teaching general hospital. Indian J Psychiatry 1982;24:366-9. 9. Gautam SK. A comprehensive study of patients presenting with somatic symptoms. Dissertation submitted to Bangalore University, Bangalore, India, 1978. 10. Avasthi A, Sharan P, Kulhara P, Malhotra S, Varma VK. Psychiatric profiles in medical- surgical populations: need for a focused approach to consultation-uaison psychiatry in developing countries. Indian J Psychiatry 1998;40:224-30. 11. Sethi BB, Gupta SC. An analysis of 2000 private hospital psychiatric patients. Indian J Psychiatry 1972;14:197-200. 12. Vahia NS, Doongaji DR, Jeste DV. Twenty five years of psychiatry in a teaching hospital (in India). Indian J Psychiatry 1974;13:253-7. 13. Khanna BG, Wig NN, Varma VK. General hospital psychiatric clinic an epidemiological study. Indian J Psychiatry 1974;16:211-20. 14. Wig NN, Shah DK. Psychiatric unit in a general hospital in India: patterns of inpatient referrals. J Indian Med Assoc 1973;60:83-6. 15. Krishnamurthy S, Shamasunder C, Prakash O, Prabhakar N. Psychiatric morbidity in general practice, a preliminary report. Indian J Psychiatry 1981;23:40-3. 16. Sriram TG, Shamasunder C, Mohan KS, Shanmugham V. Psychiatric morbidity in the medical outpatients of a general hospital. Indian J Psychiatry 1986;28:325-8. 17. Murthy RS. Editorial, emerging aspects of psychiatry in India. Indian J Psychiatry 1998;40:307-10. 18. Bhogale GS, Katte RM, Heble SP, Sinha UK, Paul BA. Psychiatric referrals in multispeciality hospital. Indian J Psychiatry 2000;42:188-94. 19. Wig NN. Psycho-Social Aspects of Family Planning. Indian J Psychiatry 1968;10:30-2. 20. Mathur RS. Psychiatric morbidity in soldiers hospitalised for physical ailments. Indian J Psychiatry 1977;19:39-96. 21. Vlrmanl V, Devi MG, Sawhneys B. B psychiatric symptoms in organic brain disease. Indian J Psychiatry 1967;9:211. 22. Dash S, Dash S. A comparative study of acceptors and rejectors of psychiatric referrals for medical termination of pregnancy. Indian J Psychiatry 1977;19:39-96. 23. Kala AK, Kala R, Bathia JC. Changing sociodemographic and clinical profile of patients attending a general hospital psychiatric clinic: some indications of community acceptance. Indian J Psychiatry 1981;22:86-91. 24. Chandra PS. The interface between psychiatry and women's reproductive and sexual health. Indian J Psychiatry 2001;43:295-305. 25. Chadda RK, Shome S. Psychiatric aspects of clinical practive in general hospitals: a survey of non-psychiatric clinicians. Indian J Psychiatry 1996;38:86-93. 26. Sarma GP. General hospital psychiatry: cost of one visit. Indian J Psychiatry 2000;42:258- 61.
S. R. Parkar, N. S. Sawant Department of Psychiatry, G.S. Medical College and King Edward Memorial Hospital, Parel, Mumbai-400 012, India 61 R o l e o f n o n - g o v e r n m e n t a l organizations in mental health in India
R. Thara, Vikram Patel
ABSTRACT
The paucity of treatment facilities and psychiatrists in the Government sector has widened the treatment gap in mental health. Non- governmental organizations (NGOs) have played a significant role in the last few decades in not only helping bridge this gap, but also by creating low cost replicable models of care. NGOs are active in a wide array of areas such as child mental health, schizophrenia and psychotic conditions, drug and alcohol abuse, dementia etc. Their activities have included treatment, rehabilitation, community care, research, training and capacity building, awareness and lobbying. This chapter outlines the activities of NGOs in India. This is a revised version of the chapter in the book on mental health to be brought out by Government of India.
Key words: India, mental health, role of NGOs
INTRODUCTION
Mental health has for decades been low in the priority of health planners at state and central levels and this is well reflected in the quantity and quality of mental health services in India. The needs of patients and families far outstrip the availability and accessibility of services for those with mental disorders. India's scarce mental health resources, such as mental health specialists, are largely concentrated in some states (mainly in the south) and in urban areas and a large proportion are solely in the private sector. Over half of all inpatient beds are located in 40 odd mental hospitals, most of which were built during the colonial years. It is not surprising, then, that the 'treatment gap' for mental disorders is large all over the country, but especially so in rural areas, northern states and amongst the socially disadvantaged.
While the government or public services are the key providers of care for these populations, and therefore need strengthening, the NGO movement in the country has seen a steady upswing in the last two decades to fill the large gaps. NGOs are driven by a passion towards a certain cause and back it up with commitment and drive. While the reach of their work cannot parallel that of government agencies, the quality of care and their efforts in reaching out to the various stakeholders, particularly those who are discriminated against such as persons with mental disorders, gives them a distinct advantage.
This chapter seeks to provide an overview of the contributions of Mental Health NGOs (MHNGOs) in India. A brief profile of some NGOs working in key and distinct areas should enable the readers to understand better the ways in which NGOs can innovate, replicate and complement state run services.
HISTORICAL ASPECTS
Non-Governmental Organizations (NGOs) are institutions, recognized by governments as non-profit or welfare oriented, which play a key role as advocates, service providers, activists and researchers on a range of issues pertaining to human and social development. Historically, NGOs have played a critical role in promoting and facilitating health and educational activities in India. Prior to independence, religious bodies set up a number of educational institutions, health facilities and other charities. These movements were often led by charismatic individuals, driven by a sense of missionary zeal. Many NGOs were born in response to major disasters and crises with the aim of providing emergency relief and rehabilitation. Since independence, there has been a meteoric rise in the profile, breadth and range of NGOs in the country.
Three key changes have occurred in the evolution of the NGO- first, the greater degree of professionalization of NGO activities; second, the widening of sources of funds for NGO activities to include major national and international donor agencies; and third, the secular origins of NGOs. The growing professionalization of NGOs led to the evolution, in the 1960s, of NGOs which focused on health issues. These NGOs increasingly filled gaps in healthcare provision, focusing on under-served populations. Some of these NGOs have now become large institutions in their own right, providing primary care services and strengthening community action for change. The activities of, now internationally acclaimed, NGOs such as the Self Employed Women's Association (SEWA), the Karuna Trust and the Aravind Eye Care group, have become models for wider adoption by the government in its own program development. Much has already been written and documented on the work of NGOs in a variety of sectors of community development issues, including health (Pachauri 1994).[1] However, there had been no such initiative in the specific area of mental health until the recent documentation of a number of NGO programs in mental health in India by the authors (Patel and Thara, 2003).[2] This chapter is based on this recent report.
DIVERSITY OF MENTAL HEALTH NON-GOVERNMENTAL ORGANIZATIONS
Despite the considerable challenges faced in developing mental health programs, it is gratifying to note the achievements made by many MHNGOs are distributed throughout the country, although there are a greater number in urban areas, and in states where there are relatively lesser pressing problems posed by poverty and communicable diseases (for example, southern states). In part, this is because these areas already have the mental health specialist resources that are often critically important in leading the development of NGO-based services. Another reason is that these are the areas of the country where the epidemiological transition is more advanced and where mental disorders account for a larger proportion of the burden of disease. Although MHNGOs are predominantly urban in location, many have begun to extend services into rural areas. Most MHNGOs serve a defined community; however, the work of some has spread to more than one center or geographical region. Examples of such NGOs are the Alzheimer and Related Disorders Society of India (ARDSI), which was started in Cochin, and has now spread to more than a dozen centers in India. Similarly, the Richmond Fellowship Society has three centers. The oldest MHNGOs in India are probably those working in the field of child mental health, and in particular, mental retardation. This may not be surprising given the close nature of the relationship between mental retardation and the concept of childhood disabilities which has been one of the bedrocks of the NGO movement for several decades. The concept of child mental health has broadened from its earlier focus on mental retardation to include the far commoner mental health problems seen in children, such as autism, hyperactivity and conduct disorders. MHNGOs such as Sangath Society (Goa) and Umeed and the Research Society (Mumbai) provide outpatient and school based services for such problems.
Other than mental retardation, the other early MHNGOs had care and treatment and rehabilitation as their priorities and developed appropriate models of rehabilitation in diverse settings and for diverse clinical populations. Their primary focus was on severe mental disorders and many of these MHNGOs (such as the Schizophrenia Research Foundation (SCARF) in Chennai, Manas in West Bengal, the Medico-Pastoral Association (MPA) in Bangalore, and Shristi in Madurai were started by psychiatrists who already held full-time faculty positions in the local medical school. These MHNGOs were started to fulfill the need for a broader, holistic approach to the management of severe mental disorders. Thus, activities ranging from family counseling to vocational rehabilitation, which were rarely provided in psychiatric out-patient clinics, were given greater attention. Another area of mental health which attracted considerable interest and attention was substance abuse. Alcohol abuse and, in particular, drug abuse captured the public imagination and received considerable media interest in the 1970s and 80s. This public attention and the obvious need for community-based rehabilitation services for persons affected by substance abuse led to the development of numerous MHNGOs working in this area. The TTK Hospital in Chennai, the TRADA in Karalla and Karnataka, Parivarthan in Maharashtra, Kripa Foundation, Alcoholics Anonymous and the Samaritans in many parts of the country and the National Addiction Research Center in Mumbai are examples of MHNGOs focusing on substance abuse problems.
National programs on alcohol and drug abuse are increasingly being implemented through grants-in-aid to such NGOs. More recently, the scope of activities of MHNGOs has broadened further, with a better understanding of the range and nature of mental health problems. Thus, stress-related disorders such as anxiety and depression are increasingly recognized as major causes of sickness and disability. MHNGOs providing community based counseling and suicide prevention activities have mushroomed. Reports highlighting the rising rates of suicide in India, in particular amongst young people, have alerted health professionals and the community about this serious mental health problem. Sneha (Chennai), MPA (Bangalore) and Saarthak (Delhi) work on suicide prevention activities; many NGOs now run help-lines for distressed persons. Some MHNGOs focus on women's mental health; common mental disorders, which are often linked to stress and oppression, are not surprisingly, more frequent in women. The activities of the Bapu Trust (Pune) demonstrate how the feminist theory can contribute to the discourse on the linkages between women's lives in a gender-biased society and their mental health. Banyan (Chennai) provides shelter and care for women living with mental disorders.
Two welcome developments in the NGO sector are the growth in user/family NGOs and the inclusion of mental health by NGOs whose original mandate was in other areas of health. Some MHNGOs, such as ACMI (Bangalore) and Aasha in Chennai are entirely run by, and focus on, families of those affected by severe mental disorders. ARDSI works with families who have a member affected by dementia. The growth of these, non-professional, family oriented MHNGO sector is to be welcomed for it is very likely that the needs of the mentally ill may be expressed and met in different ways by families and by mental health professionals. Basic Needs is an NGO which combines both service, delivery with an emphasis on livelihood skills development to empower people with mental disorders. Adolescent health interventions based on the life skills model, have become very popular in secondary schools around the country; many such programs are run in collaboration with local NGOs focusing on reproductive and sexual health issues. Targeted interventions for injectable drug users are also supported though national programs for HIV/AIDS (NACO) and implemented through NGOs focusing on HIV/AIDS (for e.g. Positive People in Goa). Many disability-focused NGOs now include mental health as a core element. An example of such an MHNGO is Ashagram in Madhya Pradesh whose primary focus was physical disabilities, especially persons affected by leprosy but which expanded it community based rehabilitation program to include severe mental disorders which also produce a profound disability in some persons. Other examples of broad- based NGOs which are integrating mental health in their agenda include the Voluntary Health Associations of India and the Community Health Cell (Bangalore). These are healthy trends facilitating the view of mental health as an integral component of the broader rubric of public health.
Despite considerable diversity in the range of objectives and types of MHNGOs as described above there are several common features shared by many of the MHNGOs. The perceived need of the community appears to have been a major catalyzing factor for the initiation and sustainability of all the MHNGOs. In some cases, personal tragedies and first hand experiences have been inspirational factors. Scepticizm and cynicism, especially of the medical community, and lack of cooperation and sensitivity of government officials and donor agencies have been uniform experiences, especially in the founding years. Not unexpectedly, a high premium is placed on involvement of families and other stakeholders in the activities and programs of all the MHNGOs. For many MHNGOs, government funding support is minimal; and most are dependant on general public or donor agencies for financial resources. A few have been able to mobilize research funds, by virtue of having established research credentials. Many MHNGOs charge fees for services. Let us now consider the kinds of activities which MHNGOs are engaged in working towards their objectives towards improving the health of those affected by mental disorders.
MENTAL HEALTH NON-GOVERNMENTAL ORGANIZATIONS ACTIVITIES AND PROGRAMS
We have grouped the activities of the MHNGOs in the following broad categories for the sake of discussion; however, there are obvious overlaps between some of these activities:
1. Treatment: care and rehabilitation 2. Community-based activities and prevention 3. Research and training 4. Advocacy and empowerment
Treatment: Care and rehabilitation
It was natural for many MHNGOs to identify treatment and rehabilitation as their priorities, based on the felt and largely unmet needs of the populations they wished to serve. Models of care and rehabilitation have been developed, many of which are replicable in diverse settings. While most state-run organizations focus on medical treatment, psycho-social rehabilitation (PSR) is sadly a neglected though major aspect of MHNGO programs. The absence of trained staff to carry out PSR activities has, however, kept it away from mainstream psychiatric services. Hence, many NGOs have taken it upon themselves to develop modules of PSR in both urban and rural areas. The programs include a spectrum of activities such as individual and group counseling, vocational rehabilitation and livelihood skills training, cognitive retraining, family support and counseling, self- help groups, recreation and leisure activities. The range of care facilities depends on the conditions which are the focus and the resources of individual NGOs. Out-patient clinics, in- patient care, day care programs and long term residential care form the spectrum of services provided by MHNGOs, especially the ones dealing with chronic psychotic conditions. Within this spectrum of services, a range of treatments including drug and psychological treatments are offered. Many persons require long-term care to minimize the disability associated with some mental disorders such as schizophrenia and dementia. Typically, about a third of patients with schizophrenia will show signs of long-term disability associated with a variety of factors such as chronic symptoms, stigma and the side effects of medication. Most MHNGOs working in this area have comprehensive services focusing both on the control of symptoms of the acute phase of the illness, as well as rehabilitation to ensure optimal functioning in the longer-term. Providing vocational training in skilled professions such as carpentry and printing, social skills training and family therapy are some examples of the kind of activities undertaken. MHNGOs provide linkages with potential employment by sensitizing employers to the needs of those suffering from chronic mental disorders.
Specific interventions targeted to groups such as children or the elderly are also being offered by some MHNGOs. In the case of child mental health, for example, interventions targeted at children, their parents and class room interventions are offered. Childhood mental disorders also require a range of rehabilitation interventions, particularly in the educational field. MHNGOs working in other areas, such as substance abuse, also provide a range of rehabilitation services. Community programs and prevention
Although the National Mental Health Program was initiated in 1983 to ensure minimum standards of mental health care by integration with existing primary healthcare services, this still remains a utopian dream in almost all parts of the country. A major reason for this is the almost complete biomedical emphasis of the program with an outpatient clinic where medicines are doled out in a health centre being the principal and, indeed in most places, the only form of care which is provided. On the other hand, NGOs have initiated a number of community-based mental health programs emphasizing on services in a variety of community, including home-based, settings and offer a range of PSR activities. These programs range from primary prevention activities such as suicide prevention (see below) to provision of treatment in community clinics, increasing awareness and providing community based rehabilitation (CBR). NGOs are arguably better placed to approach and win the trust of local communities, establish ties with them and locate their programs in and for the community. Examples of primary prevention programs are the telephone help lines for depressed and suicidal persons, early intervention for babies born at risk for developmental delay and education programs in schools and workplaces for prevention of substance abuse.
Secondary prevention focuses on minimizing the handicaps associated with an existing mental disorder. Examples of such programs include CBR programs for child and adult mental disabilities and school programs to help children with hyperactivity and dyslexia stay in school. CBR is an essential ingredient of community care programs. SCARF, as part of vocational support activities, has distributed livestock, cows and helped expansion of petty shops in rural areas to help persons with schizophrenia. This is not just a means of livelihood, but has also improved their functioning and involvement in many ways. Empowerment of the local community is equally important and involvement of key and influential persons in the community such as teachers, religious heads, and local administrators has yielded good results. Basic Needs is another MHNGO which emphasizes on such CBR activities as the core component of its mental health program. Community programs gained much significance when the tsunami left in its wake a number of psycho-social problems which required intensive counseling, support and sometimes medication to allay anxiety and depression. NGOs like SNEHA (Chennai) provided a range of community based counseling and mental health interventions in the aftermath of this disaster. In keeping with latest advances in technology and communications, SCARF has started using telemedicine to expand access to specialist mental health services in rural areas. Homelessness and the destitute mentally ill have also received growing attention in the last decade or so. NGOs such as Banyan and Anbagam in Chennai, Ashadeep in Guwahati and Samarpan in Indore, and a few others, have developed comprehensive services for the "wandering" mentally ill. However, to sustain these programs, a national plan is required for the provision of care to the homeless and wandering mentally ill, whose plight is borne out of a combination of health, socio-economic and human rights issues.
In the 1970s and 80s, there was a mushrooming of NGOs to deal with substance abuse, but few of these organizations have sustained themselves. The TTK hospital/TT Ranganathan Clinical Research Foundation started in 1980 in Chennai is an organization which has expanded itself in various activities and become a referral center for training and awareness building in substance abuse. This NGO has been active in the various fields of out-patient and in-patient care, extending care to those who need it through community outreach programs and CBR activities.
The Indian Alcohol Policy Alliance, a network of centers and individuals working in de-addiction have released an" "Alcohol Atlas of India" as a reference guide for policy makers and professionals The National Addiction Research Centre (NARC), established in 1985, is another example of an NGO focusing on substance abuse who have sustained their activities, in part due to the growing emphasis on drug users as a target population for HIV/AIDS control.
Research and training
Until relatively recently, MHNGOs were primarily concerned with service provision and advocacy related activities. Research was considered as an academic exercise, best reserved for the ivory towers of universities and teaching hospitals. This has changed so much in recent years that today MHNGOs are at the forefront of ground-breaking health research in India. Major research programs in health areas as diverse as infectious diseases to nutrition are now conducted under the aegis of NGOs. MHNGOs are no exception to this trend. The SCARF studies on schizophrenia are the most widely-cited research on the subject from any developing countries (Thara and McCreadie 1998).[3] All three published studies of dementia in the community in India are from work done by MHNGOs (REF). Sangath's studies on the treatment of depression are amongst the largest such studies from India (Patel et al. 2003),[4] Sangath's Manas project is the largest trial for a mental health treatment from any developing country. Ashagram's community program for schizophrenia has generated the first scientific evidence of the use of the CBR approach for rehabilitation of a mental disorder (Chatterjee et al. 2003).[5] The experience of CBR in Ashagram has led to the initiation of the first randomized controlled trial of this approach in three sites in India. These are just some examples of innovative, action- oriented research emanating from MHNGOs.
Many MHNGOs actively invest in the development of skills of their staff and of other stakeholder groups. Participation in workshops, conferences and seminars, and formal training in courses such as rehabilitation are often offered as opportunities for career development. Most of the MHNGOs provide opportunities for training other professionals and health workers in specific areas of mental health, such as counseling skills. Many colleges, for example, send their students to MHNGOs for field placements. Workshops with health workers, teachers and other key groups are a standard feature of the activities of many MHNGOs. Many of these organizations regularly conduct local, national or international conferences, seminars, workshops and symposia to discuss current issues in this field (Kalyanasundaram and Varghese, 2000).[6]
The Richmond Fellowship has successfully established a full two-year MSc program in psychosocial rehabilitation. Two NGOs (Sangath and SCARF) launched a new course ("Leadership in Mental Health") in 2008 to strengthen skills on scaling up services for people living with mental disorders. The course attracts students from around the world.
Advocacy and building awareness
Advocating for the needs of under-served and underprivileged sections of the population has been the raison d'etre for most MHNGOs. At present, there is very low awareness of the considerable advances in our knowledge of the causes and treatment of mental disorders in India This low awareness, coupled with the enormous stigma attached to mental illness, means that the needs and rights of mentally ill persons are largely ignored. MHNGOs have made raising awareness in different sectors of the community, such as health workers, teachers and lay persons, a priority area. Documentation and dissemination of relevant facts and research, and lobbying policy makers for changes in the law are vital instruments for improving mental healthcare. A prominent example of the success of efforts of MHNGOs is the inclusion of mental disabilities in the disability legislation of the country. The film festival organized by SCARF called the "Frame of Mind," which features several films portraying mental illness and an international competition for short films on mental health and stigma, is a huge success and has had three editions so far. Similar festivals have since been held in other cities like Kolkata. Many NGOs use short films to spread awareness about their work/cause. Many publish regular newsletters and host web sites marking the close affinity of MHNGOs with contemporary technological advances. Many MHNGOs adopt methods to enhance the effectiveness of care through empowerment of affected persons and their families. Support groups are widely used as a way to ensure that persons recovering from substance abuse can remain sober. The globally recognized organization, Alcoholics Anonymous, is an example of the kind of support group philosophy which becomes the core to the process of treatment of alcohol dependence. Support groups are also evident in the residential and day care facilities geared to those with severe mental disorders. Some MHNGOs run support groups not for those directly affected by a particular disorder, but for their families. Thus, families of elders with Alzheimer's disease, adults with schizophrenia and children with autism, meet regularly to discuss common problems, support each other and provide practical solutions to everyday difficulties. Advocacy led by such user and family NGOs may have particularly important impact on government policies. The All India Federation for Mental Health, an umbrella organization of many NGOs working in the field of mental health, and the National Association of the Mentally Ill (NAMI- India) are examples of coalitions of NGOs and consumers respectively which are actively advocating for mental heath policy and care reforms in India.
MENTAL HEALTH NON-GOVERNMENTAL ORGANIZATIONS STRENGTHS AND LIMITATIONS
Why is it that the MHNGO movement has continued to survive despite the lack of resources and other barrriers? This is probably because MHNGOs have some inherent and intrinsic advantages. We can consider the advantages of MHNGOs under three broad categories: Working in Partnership, Innovations in Practice and Transparency in Administration.
• Working in partnerships: One of the great strengths of MHNGOs is their ability to strike up collaborations and partnerships with other agencies or individuals with ease; unlike the public health sector where layers of permissions stifle the scope for collaboration and unlike the private health sector where collaborations may be perceived as a threat to the practice. Most MHGNO activities are provided by multidisciplinary teams of doctors, therapists, health workers, other professionals and volunteers. Partnerships are built not only between medical and non-medical professionals, but also between professionals and families. The close collaboration between academics, clinicians, social workers, rehabilitation workers, remedial teachers, clinical and educational psychologists are a distinct feature which marks MHNGOs as being a very different breed of animal from traditional psychiatric clinics in hospitals or private psychiatry.
• Innovations in practice: MHNGOs are, typically, closer to the community they serve and hence in a better position to be more sensitive to changing needs and perceptions. Further, MHNGO services may be attached with much less stigma than formal psychiatric services, and may thus attract a much wider range of clients. Clinical support, involving diagnosis and treatment of specific mental disorders, is the key to many MHNGO activities. The success of MHNGOs lies in providing services which are accessible, such as through outreach camps, which rely on available human resources, such as the community participatory model of rehabilitation. Many MHNGOs provide a wide range of services which are especially suited for severe and childhood mental health problems. By taking up the process of promoting attitudinal changes in the community and amongst policy makers, MHNGOs also play a key role in advocacy for changes which can benefit all persons with mental illness.
• Transparency in administration: The activities of MHNGOs are driven not by profit but by the desire to achieve a basic quality of care for all clients, irrespective of their ability to pay. They are governed by a relative flexible set of regulations. Employment and promotional avenues can be based on merit as opposed to the traditional governmental holy grail of seniority. Because they are dependent on external funding, MHNGOs are constantly kept on their toes in achieving program objectives and ensuring fiscal accountability. MHNGOs can explore, with remarkable entrepreneurial dynamism, collaborations with any other organization or individual to achieve their objectives.
However, MHNGOs have their fair share of limitations and problems. We can consider these under the broad themes of Sustainability, Accountability and Scope.
• Sustainability: A key problem facing most MHNGOs is the source of their funding, which is largely project- based. The periodic fund raising required to augment resources can take up a good deal of time and energy. Staff members have no guarantee of employment beyond a defined project period. As a consequence, some MHNGOs suffer a high turn over of staff. This is partly because staffs are appointed on specific funded projects and their continuity depends on the funding available. There might be a temptation to dilute goals and objectives as a response to availability of funding. Donor funding is notoriously fickle; priorities change over time, and MHNGOs often reinvent their objectives to keep afloat. The recent trend for massive investment in HIV/AIDS related work, though important in its objectives, is concentrating the bulk of donor money to this one- disease issue. Many MHNGOs and, indeed, some MHNGOs are adding HIV/AIDS as core priorities to secure these funds. While this may broaden the scope of MHNGOs by enabling an integration of existing priorities with new ones, there is equally a need not to allow the focus on mental health to be diluted to the point that it becomes irrelevant
• Accountability: Some MHNGOs have poorly established mechanisms for evaluation and monitoring. Although networking is actively sought for project collaboration, there is no similar zeal for review and monitoring from external assessors. There has been considerable public concern regarding the misuse of funds and lack of financial accountability of NGOs in general. Although this may not be as significant an issue in the context of MHNGOs where funds are scarce, MHNGOs would be well advised to ensure transparency in accounting for their funds. As MHNGOs become larger and more professionalized, there is a danger of increasing bureaucratization with increasing administrative costs. MHNGOs should be wary of this from the beginning since it could well dampen creativity and flexibility, two elements which give MHNGOs their unique flavor.
• Scope: Finally, and perhaps the most important limitation is the limited scope of individual MHNGOs. The world of most MHNGOs is confined to a city or a few villages. There is, however, a need to transplant the wide experience of these onto a larger canvas, ideally through influencing policies and programs for the entire state and country. For changes to occur on this wider canvas there is little doubt that the public or government health sector must play a key and leading role. MHNGOs can, in this context, be seen as innovators who develop locally relevant models which can then be implemented on a national scale.
CONCLUSION
MHNGOs have made tremendous strides in mental health promotion and care, against massive odds ranging from low awareness about mental illness to lack of motivation donors. Although there can be little dispute whether the MHNGOs have a definite role to play in meeting mental health needs in India, there is also little doubt that their impact on mental health care at the national level has been marginal. For example, there are very few MHNGOs working in rural or impoverished areas. The strength of MHNGOs does not lie in their ability to reach out to the millions of persons with mental disorders, but in evolving and perfecting quality programs and models which have the character of replicability. Through innovation and accountability, MHNGOs can provide models for the public healthcare system to emulate and partner. However, they cannot entirely meet the needs of the under-served and underprivileged sectors of our population. That responsibility, was, is, and must rest principally with the public health sector. We believe that the time and setting is right not only for the emergence of new MHNGOs, but also for the consolidation and strengthening of existing ones. We specifically call for the inclusion of MHNGOs as full partners of the government services in the National Mental Health Program. Such a partnership could take several forms.
1. Participation in intersectoral committees to monitor and implement the NMHP in each district, involving government, NGO and psychiatric stakeholder representation. These committees can be empowered to take on roles of combating stigma, supporting user groups, monitoring rights, and capacity building.
2. NGOs running DMHP following the model of NGOs adopting primary health centers in some districts; here NGOs become providers of the DMHP services, especially in districts where government mental health services are weak.
3. NGOs developing niche community based services including day care centers and residential facilities for chronically disabled patients or children or mental health promotion activities, help lines for distressed suicidal patients, facilitating user and family support groups and assisting with livelihoods and employment generation and so on.
4. NGO placements becoming mandatory for psychiatric training for doctors and nurses whose current training programs are mainly hospital based, thereby missing out on the entire range of community-based and PSR experiences.
5. NGO representation should be sought in all committees, task forces involved with planning of mental health activities and program implementations at the state and national levels.
We urge the government agencies to take note of the huge public health implications of mental disorder and the lack of organized services for the mentally ill, and provide support for MHNGOs in the ways proposed above. Given a favorable climate, we are sure that the MHNGO movement in Mental Health will not be a sporadic or isolated phenomenon as it is now, but a more enduring and unified force in the realm of Mental Health in India.
REFERENCES
1. Pachauri S, editor. Reaching India's Poor: Non-governmental approaches to community health Sage (India), New Delhi. 2. Patel V, Thara R, editors. Meeting Mental Health Needs in Developing Countries: NGO Innovations in India Sage (India), New Delhi. 2003.1994. 3. Thara R, McCreadie RG. Research in India: success through collaboration. Adv Psychiatric Treat 1998;5:221-4. 4. Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A. The efficacy and cost-effectiveness of a drug and psychological treatment for common mental disorders in general health care in Goa, India: A randomised controlled trial. Lancet 2003;361:33-9 5. Chatterjee S, Patel V, Chatterjee A, Weiss H. Evaluation of a community based rehabilitation model for chronic schizophrenia in a rural region of India. Br J Psychiatry 2003;182:57-62. 6. Kalyanasundaram S, Varghese M, editors. 'Innovations in Psychiatric Rehabilitation', Proceedings of the RF-ASPAC International Symposium (1995) at Bangalore, Richmond Fellowship Society, Bangalore, 2000.
R. Thara Schizophrenia Research Foundation Chennai.
Vikram Patel London School of Hygiene and Tropical Medicine and Sangath Goa, India 62 Women psychiatrists in India: A reflection of their contributions
Mamta Sood, Rakesh K. Chadda
ABSTRACT
The increasing number of women joining psychiatry is a relatively new phenomenon in the field of medicine. Keeping with the trends world over, the number of women psychiatrists in India has been on the rise over the last two to three decades. The authors searched various volumes of the Indian Journal of Psychiatry, recent membership directories of the Indian Psychiatric Society, website of the Medical Council of India and personal communications for contributions of the women psychiatrists in India. Women psychiatrists have a number of contributions to their credit in India. They have played important roles in the affairs of national professional organizations like the Indian Psychiatric Society and have contributed to the psychiatry education and research. However, they also suffer limitations because of the absence of adequate institutional support and policies looking into their specific needs.
Key words: India, psychiatrists, women
INTRODUCTION
There has been a significant increase in the number of women doctors joining psychiatry in India in the last two to three decades. Until early 1980s, their number could be counted in single digit. Historically, the discipline of psychiatry has often been considered to be associated with unpredictable and violent patients, and had a number of misconceptions attached to it; trends are changing now. Reasons for psychiatry becoming a preferred career choice for women doctors can be traced to multiple factors. Psychiatry has gradually shifted out of the high walls of the mental hospitals to the general hospital and community settings and is gaining more acceptability and respect in the society. The medical profession is also synonymous with long years of training followed by long hours at work almost every day. Over and above this, women doctors have to juggle career and family responsibilities as domestic and child related duties have largely remained with them despite changing roles. The crucial career-intensive years in professional life (residency and early years as junior faculty) coincide with the equally crucial period (marriage, childbearing and child rearing) in the personal life. A career in psychiatry allows doing justice to multiple roles in a better way than the other busy clinical specialties like gynecology and obstetrics, pediatrics, internal medicine, cardiology or surgical disciplines, because of the possibility of predictable working hours, less emergencies, flexible working schedules and greater opportunities to interact with patients.[1]
The increasing trends of psychiatry as a specialty choice for women doctors in India have remained in tandem with trends world over, albeit late by about a decade. For example, in the USA, psychiatry has the fourth highest number of women specialists and 40-45% of first-year residents in psychiatry are women.[2] In the UK and Ireland, women form 45-48% of the specialist trainees.[3] In Canada, the percentage of women psychiatric residents increased from 23.5% to 43.4% over a period of 10 years from 1970s to 1980s.[4]
In contrast to the high income countries where various issues related to women psychiatrists like their numbers, needs and concerns, defining characteristics and reasons for their lagging behind men have been researched and debated, there is virtual lack of data about the issues related to women psychiatrists in India.[5] Research has documented that their working styles have been noted to be different from their male colleagues in some aspects. Many women psychiatrists are noted to be more empathic in approach. Their patients report better satisfaction levels as they are more likely to engage patients as active partners in the care by adopting a democratic style of communication. They spend a significantly greater proportion of time on preventive services and counseling, compared to their male colleagues.[6] As a group, they lag behind their men colleagues in attaining positions of authority and leadership in academics, professional organizations, and medical institutions. For example, women constitute 29% of associate professors, 15% of full professors, and 6% of department chairs in medical schools in USA.[7] In England also, women psychiatrists are significantly less likely to pursue an academic career and professional position than men.[8] There are some reports that the women psychiatrists have poorer coping skills, more physical and emotional symptoms, and are more likely to report stress, anxiety and depression.[9]
The present paper aims at bringing out contributions made by Indian women psychiatrists to the field of psychiatry and society. The paper presents information available on women psychiatrists in India in terms of their numbers, concerns and research interests, important positions held by them in academia and various national bodies.
MATERIALS AND METHODS
Indian Psychiatric Society, the national body of psychiatrists in India, is more than 60 years old. It publishes a directory of its members periodically. Membership directories of the Society, published in 2006 and 2009,[10-11] and all the volumes of Indian Journal of Psychiatry (1958-2009), and Indian Journal of Neurology and Psychiatry (1949-1953), the official publication of Indian Psychiatric Society were searched manually for the articles published, with women as first author. The official website of Medical Council of India was also searched for relevant information.[12]
RESULTS AND DISCUSSION
Number of women psychiatrists in India
Women psychiatrists constitute 14.6% of the total membership (2829) of Indian Psychiatric Society.[10] They constitute about 10% of the fellows and 20% of the ordinary members; a member of the society becomes eligible for fellow after five years post qualification experience in the psychiatry. These figures suggest that the number of women at relatively senior level is less. It is possibly due to the fact that the number of women doctors joining psychiatry has started increasing only recently as suggested by higher percentage of members with less than five years post qualification experience.
Women psychiatrists are represented in different sectors like general hospital psychiatric units, psychiatric hospitals and the office based practice. Exact figures of the gender based distribution of psychiatrists, in different settings, is not available. Although every year, 134 posts are available for postgraduate degree and 96 for postgraduate diploma in psychiatry,[12] it is not known how many women join these postgraduate courses every year. However, women have formed about 20% of the candidates joining psychiatry residency in the last five years at the All India Institute of Medical Sciences, New Delhi (authors' medical school), one of the premier medical institutions of the country. These figures are not different from the total percentage of women doctors joining the institute for post graduation in various medical and surgical disciplines in the last five years. [5] It may not be appropriate to generalize these figures, but these provide some trends.
Most of the premier medical schools of the country have women faculty; a few of them are professors. However, most of them are at relatively junior positions. It is not known, how many have been heads of departments of psychiatry in different medical colleges or hospitals across the country. We could identify only a few. A few women have also been known to have headed a psychiatric hospital or a medical college.
Indian Psychiatric Society
Currently, there is no female office bearer in the Indian Psychiatric Society and only one of the council members is a woman. However, since its inception in 1947, women psychiatrists have held the post of president four times: Prof. Ajita Chakraborty in 1976, Prof. Roshan Master in 1981, Prof. Jaya Nagaraja in 1983 and Prof. Deepali Dutta in 1990. Prof. Ajita Chakraborty has also held the post of general secretary of the society in 1967 and 1968. Though the society has been publishing its journal, the Indian Journal of Psychiatry, for more than 50 years, it never had a woman editor. In the current editorial board, there is no woman psychiatrist; only one is in the journal committee.[10] At present, one woman is the chairperson of the Society's committee on psychiatry education. Three women are either chairpersons or conveners of the Society's task forces on women and mental health and suicide prevention.[11] Many women psychiatrists have received national as well as international recognitions.
Indian Journal of Psychiatry[5,13-183]
We were able to retrieve about 170 papers, which had women as first authors. There were only 45 papers published prior to 1980. However, we could identify only a limited number of women psychiatrists, who had published before 1980. They have contributed original papers, critiques, reviews and book reviews. The area of research is varied and includes psychopathology, child psychiatry, culture specific syndromes, neuroses, psychopharmacology and psychological testing. The women from allied branches like psychology, social work, occupational therapy and psychiatry nursing have also published in the journal. Interestingly, the women psychiatrists, who have contributed to the journal, were mostly from big cities, and almost all belonged to medical schools.
Probably, Dr. (Miss) Mani B Ghamat was the first woman psychiatrist to publish an article in the earlier version of the journal, Indian Journal of Neurology and Psychiatry in 1952.[65] She worked as assistant psychiatrist at JJ Hospitals, Bombay. She was also probably the first women psychiatrist recorded to be a member of the society. Prof. Ajita Chakarborty, Prof. Roshan Master, Prof. Erna Hoch, Prof. M. Sarada Menon, Prof. Deepali Dutta were some of the pioneer women researchers. Prof. Ajita Chakarborty has published extensively on epidemiology, culture specific issues in mental health, child psychiatry and psychopathology. Prof. Roshan Master wrote about psychopathology and psychopharmacology. She also wrote many excellent book reviews. Prof. Erna Hoch wrote about many important social and cultural issues. Prof. M. Sarada Menon contributed to research on psychopharmacology and was also instrumental in setting up the Schizophrenia Research Foundation (SCARF) at Chennai, which has been a trendsetter non-governmental organization (NGO) in the field of mental health. She worked extensively on rehabilitation of schizophrenia. Prof. Deepali Dutta wrote about the issues related to child mental health. Interestingly, Smt Shakuntala Pranjapye, one of the authors in the journal in 1963, was a member of legislative council of Maharashtra.[125]
The number of women psychiatrists who have published in the journal started increasing from 1980 onwards. Women from all types of work settings like medical colleges, private practice and services have contributed to the journal. It was a pleasant surprise that now woman psychiatrists not only from metros but even from smaller cities have also been publishing. Majority of the papers are original articles and some are case reports. However, reviews, invited articles, presidential addresses, editorials, commentaries, orations and critiques by women authors in the journal could be counted on fingers and were less than five in each category.
Interestingly, in the journal, only one woman psychiatrist has published more than 10 times, 17 have published twice, 10 have published less than 10 articles each and rest have published only once. This highlights the fact that women psychiatrists do publish initially but for reasons not researched yet, start leaving the academics. The reason for not publishing is apparently not due to lack of interest. It is possible that similar trends may be found for male psychiatrists. On pursuing the topics researched, it becomes apparent that they have interest in wide ranging subjects of psychiatry from biological to psychosocial underpinnings of various psychiatric disorders, epidemiology, biopsychosocial treatments, consultation liaison psychiatry, child psychiatry, suicide, severe and common mental disorders and de-addiction. A few women psychiatrists of Indian origin, now settled abroad, have also contributed to the journal.
The areas where women psychiatrists have established themselves as leaders are child psychiatry, schizophrenia, disability, suicide and mental health issues related to women.
Other issues
There are no studies available comparing women and men psychiatrists in terms of their specific needs, aspirations, areas of interest, monetary incentives, working styles, characteristics and other issues. There are no guidelines for pregnancy and maternity leave for women doctors and post graduate trainees from the Medical Council of India, the regulatory body for medical matters in India. A post graduate trainee has to attend not less than 80% of the training during each calendar year. If pregnancy occurs during the period of postgraduate training, either the resident has to manage within the permitted time of not attending or has to postpone her examination. For those in a government sector job, there is a provision for maternity leave of 180 days.[184] Only a few hospitals or medical colleges provide reliable onsite daycare. School-based childcare is usually not available when children are older. On discontinuation of a job for family-building or other reasons, options for revival of career after a certain period are presently unavailable due to restrictions in age of entry and qualification for jobs at different levels. Currently there are no regulations or policies from government which address these issues. There is little opportunity for flexible training, creative scheduling of job or training if a woman wants to come back to academics after a gap due to child care responsibility. Unlike some of the high income countries, there is no central or state organization/union/association of women psychiatrists at regional or national level in India.
Although the country is credited for having the first woman Prime Minister in the region, currently there are very few women psychiatrists in top positions of the Indian Psychiatric Society or other national bodies despite their increasing numbers. Therefore, at present, the role of women psychiatrists in policy making of the specialty remains negligible. This is in contrast to earlier times when although women psychiatrists were less in number, they held important positions in the Indian Psychiatric Society. The gender inequity in promotion has been explained by the fact that women, because of family obligations, work fewer hours, are less productive, and have a limited publication record. Women have often fewer mentors and professional networks and less collegial support while in the academic medical system.[185]
We have attempted to access information about Indian women psychiatrists from multiple sources, and have presented the information whatever we could get. We offer our apologies if we have missed some important contributions of the Indian women psychiatrists.
CONCLUSION
The number of women psychiatrists in India is on the rise in the recent years. Indian women psychiatrists have many contributions to their credit. Many of them have served or are serving as faculty in medical schools and have also contributed significantly to psychiatry education at undergraduate and postgraduate level. They have left their marks on various areas of psychiatry; significant among them are child psychiatry, suicide and its prevention, community psychiatry, rehabilitation of patients with schizophrenia and issues related to women mental health. But to succeed and flourish, they need support systems both at home and workplace. The profession and the government have to innovate in finding ways to maximize the optimal use of the substantial talent pool and intellectual capital of women psychiatrists.
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Mamta Sood Rakesh K. Chadda Department of Psychiatry All India Institute of Medical Sciences New Delhi - 110 029, India