archives of mental health -...

Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018 i

Archives of Mental HealthEditor

Dr. P. Vijayalakshmi Consultant Psychiatrist, Sparsha Psychiatry Clinic, Bharathi Health Centre, Vijayawada-A.P

National Editorial Board

T Sathyanarayana Rao MDProfessor and Head, Department of Psychiatry, JSS Medical College, Mysore, Editor Indian Journal of Psychiatry

Rajasekhar Bipeta DNBAssociate Professor, Gandhi Medical College, Hyderabad

Lokeshwara Reddy Pabbathi MDAssociate Professor, Guntur Medical College, Guntur

B. N. Gangadhar MDProfessor of Psychiatry, Director NIMHANS, Program Director,

NIMHANS Integrated Centre for YogaB. Anand DNB

Professor and HOD Psychiatry, MRIMS, HyderabadProf. Roy Abraham Kallivayalil MD

Secretary General, World Psychiatric Association, Vice-Principal, Professor & Head, Dept of Psychiatry, Pushpagiri Institute of Medical Sciences,

Tiruvalla, KeralaRama Reddy Karri MD

(Founder Editor of Andhra Pradesh Journal of Psychological Medicine)Director/Consultant Psychiatrist, Manasa Hospital, Rajamahendravaram

Soumitra S Datta DNB MD MRCPsy CCTSenior Consultant Psychiatrist, Department of Palliative Care and

Psycho-oncology, Tata Medical Centre, Kolkata, IndiaChittaranjan Andrade MD

Dean (Basic Sciences), Professor and Head, Department of Psychopharmacology, National Institute of Mental Health and

Neurosciences, Bangalore G Prasad Rao MD

Consultant Psychiatrist, Director, Schizophrenia & Psychopharmacology Division, Asha Hospital, Hyderabad

NN Raju MDMaharshi, Masjid Jn, Nr. Jagadamba, Visakhapatnam

Suja Kurian MD CCSTProfessor and Head, Unit III, Dept. of Psychiatry, CMC,

Vellore, Tamil NaduAjit Avasthi, MD

Professor & Head, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh

Prabhakar Korada DNBHyderabad

Anindya Kumar Ray MDAssistant Professor Psychiatry, Malda Medical College,

Government of West BengalK. Ashok Reddy MD

Director, Govt. Medical College, MAHABUBNAGAR. T.S.Padma Sudhakar T MD

Consultant Psychiatrist; Professor and Head, Department of Psychiatry, Sri Padmavathi Medical College, Tirupati, India

Padmavati Ramachandran MDJoint Director, Schizophrenia Research Foundation (SCARF), Consultant

Psychiatrist, Chennai, IndiaIndla Ramasubba Reddy MD Director,

Consultant Psychiatrist, Vijayawada Institute of Mental Health And Neurological Sciences (VIMHANS),Vijayawada, India

Uday Kumar K MD Professor of Psychiatry, Narayana Medical College, Consultant Psychiatrist,

Nellore, IndiaY C Janardhan Reddy MD

Professor of Psychiatry; Consultant, OCD Clinic; NIMHANS, Bangalore, India

Advisors

Dhana Ratna Shakya, MDEditor-in-chief, J BPKIHS, Head, Nepal National Unit of UNESCO Chair in Bioethics, Professor, BP Koirala Institute of Health Sciences (BPKIHS),

Dharan, NepalMatcheri S. Keshavan MD MNAMS FRCPsy

Stanley Cobb Professor and Vice-Chair for Public Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School. Editor in Chief, Schizophrenia Research, Director, Commonwealth Research Center

Dinesh Bhugra MBBS, FRCP, FRCPEdin, FRCPsych,FFPH, MPhil, PhD, FRC Psych (Hon), FACP (Hon), FHKC, Psych (Hon), FAMS (Singapore), FIMSA (Hon), MAcad MEd, Professor of Mental Health and Cultural Diversity, Health, Service and Population Research Department, Institute of Psychiatry (King’s College). Honorary Consultant, South London and

Maudsley NHS TrustMaureen Rubin, Ph.D., MSW

Assistant Professor, School of Social Work, University of Nevada, Reno, 1664 N. Virginia StreetFarooq Ahmed Khan MBBS, MD, MRCPsych

Consultant Psychiatrist, Birmingham & Solihull Mental, Health NHS Foundation Trust. Honorary Lecturer, Old Age, Psychiatry, Centre for Ageing and Mental Health, Staffordshire University, England

Tejam P MDConsultant Psychiatrist, Shortely Bridge Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust, United Kingdom

International Editorial Board

Chief Advisor

ii Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018

Archives of Mental HealthIndian Psychiatry Society-Andhra Pradesh State Branch

Executive Council Members: 2017-2018

PresidentDr.Vishal Reddy Indla, Vijayawada

E-mail: [email protected],[email protected]

Vice - President Dr. P. Srinivasa Teja, Nellore

E-mail [email protected]

Hon. General Secretary Dr. Chandra Balaji N.R.P, Nellore

E-mail: [email protected], [email protected]

Hon. TreasurerDr. Y. Prabhakar, Ananthapuramu

E-mail : [email protected], [email protected]

Hon. Editor Dr. P.Vijaya Lakshmi, Vijayawada

E-mail: [email protected] , [email protected]

Immediate Past PresidentDr. Nagi Reddy, Kurnool

Immediate Past SecretaryDr. B. Ramesh Babu, Kurnool

EXECUTIVE COMMITTEE MEMBERS

Dr. G. MURALIDHAR, NelloreDr. K.V. RAMI REDDY, Vizag

Dr. M. VENKATA RAMANA, BhimavaramDr. A. VIJAY CHANDRA REDDY, Kadapa

Dr. R. VENKATA RAMUDU, Kadapa

CONSTITUTION COMMITTEE MEMBERS

Dr. I. RAMA SUBBA REDDY, VijayawadaDr. P. HIMAKAR, Vizag

TASK FORCE COMMITTEE MEMBERS

Dr. K. RAMA REDDY, RajamahendravaramDr. K. NARASIMHA REDDY, Vizag

Dr. G. V. RAMANA RAO, Bhimavaram

A.P. REPRESENTATIVE TO SOUTH ZONEDr. G. SURESH KUMAR, Vizag

Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018 iii

Archives of Mental HealthGeneral Information

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Archives of Mental Health, a publication of Indian Psychiatric Society-Andhra Pradesh Branch, is a peer-reviewed print + online biannual journal. The journal's full text is available online at www.amhonline.org. The journal was previously published as ‘Andhra Pradesh Journal of Psychological Medicine’ and has changed its name to ‘Archives of Mental Health’ since 2018. The journal allows free access (Open Access) to its contents and permits authors to self-archive final accepted version of the articles on any OAI-compliant institutional / subject-based repository.

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Editorial OfficeDr. Pernenkil Vijayalakshmi Editor in Chief Archives of Mental Health 40-14-4 Chandramoulipuram, Vijayawada, Andhra Pradesh - 520 010, India. Tel: Mobile: 98489 92255. E-mail: [email protected]

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iv Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018

Archives of Mental HealthVolume 19 - Number 1 - January - June 2018

C O N T E N T S

EditorialMeditation – The next step in evolutionVijayalakshmi Pernenkil ................................................................................................................................................... 1

Review ArticlesStem cell therapy role in neurodegenerative disordersPasam Ravisankar, Koppineedi Dhanavardhan, Kompella Prathyusha, Kattula Rao Vinay Rajan ................................. 3

Mental Health Care Act 2017: Review and upcoming issuesPrasanna Kumar Neredumilli, V. Padma, S. Radharani .................................................................................................. 9

Original ArticlesClinical profile and changes in values of mean platelet volume among panic disorder patientsSanjay Yalamanchili, Sai Kiran Pasupula, Raviteja Chilukuri ........................................................................................ 15

Caregiver burden in alcohol dependence syndrome in relation to the severity of dependenceR. S. Swaroopachary, Lokesh Kumar Kalasapati, Sarath Chandra Ivaturi, C. M. Pavan Kumar Reddy ....................... 19

Internet addictive behaviors and subjective well‑being among 1st‑year medical studentsVedalaveni Chowdappa Suresh, Wilma Delphine Silvia, Haradanahalli Giriprakash Kshamaa, Swarna Buddha Nayak .................................................................................................................................................. 24

Reasons for pursuing psychiatry as a career: A qualitative study of future psychiatrists from IndiaPriya Sreedaran, Divya Hegde ...................................................................................................................................... 30

Disability in bipolar affective disorder patients in relation to the duration of illness and current affective stateR. S. Swaroopachary, Lokesh Kumar Kalasapati, Sarath Chandra Ivaturi, C. M. Pavan Kumar Reddy ....................... 37

Chronic pain and psychological distress among adults in UdupiParamjot Panda, Suchismita Panda .............................................................................................................................. 42

Case ReportAnorexia nervosa in rural South IndiaKeya Das, K. S. Ashok .................................................................................................................................................. 47

© 2018 Archives of Mental Health | Published by Wolters Kluwer - Medknow 1

Meditation – The next step in evolutionUntreated mental disorders account for 13% of the global burden of disease. “Current predictions indicate that by 2030, depression will be the leading cause of disease burden globally.” How do we tackle such a scenario?[1]

The rational part of the brain is the functioning of intact prefrontal cortex (PFC). The emotion filled part of us is mostly the functioning of a tiny almond-shaped body in our brain called the amygdala. This organ stores emotional memory. A well-developed PFC – which only humans are endowed with – in addition to executive and a host of other functions – regulates emotions.[2] There are certain situations when the amygdala hijacks the brain and hinders the normal functioning of the PFC. Dr. Daniel Goleman in his thought-provoking book “Emotional intelligence” calls the act of amygdala as emotional hijacking.[3] It is a fact that our senses relay to the thalamus which in turn sends a small bundle of neurons to the amygdala and a longer bundle to the neocortex which in turn relays to the amygdala. Therefore, the neocortex usually regulates emotional expression. The shorter pathway allows the amygdala to receive some direct input from the senses and to start a response even before they are fully registered by the neocortex. This is the basis of the emotional hijacking. Amygdala being a repository for emotional memory scans the experience comparing what is happening now with what happened in the past. Its method of comparison is associative. When one key element of a present situation is similar to the past, it can call it a match, thus over generalizing situations and flooding our system with overwhelming emotions not regulated by the PFC.[3] The PFC is an efficient manager of emotions. It dampens the signals for activation sent out by the amygdala and other limbic structures.

The strengthening of PFC is possible through meditation. Meditation increases the cerebral blood flow more to the left medial PFC and also the insula. The increased cerebral blood flow to the left PFC is associated with positive emotions such as happiness and flexible behavior that is not automatic. This is due to more of parasympathetic activity when compared to sympathetic nervous system activity. Increased blood flow to the insula is associated with appropriate emotional regulation. The blood flow to the parietal cortex is decreased. Parietal cortex is associated

with spatial processing; therefore, the sense of space is gradually lost.[4]

Meditation causes neuroplasticity (number of connections between neurons increase). There is increased gray matter concentration in the posterior cingulate cortex, temporoparietal junction, hippocampus, brainstem, and cerebellum. It was also found that the cortex in meditators was thicker than nonmeditators and similar to the cortex of nonmeditators 20 years younger. The PFC and insula were thicker in meditators, and the region in the brain most associated with emotional reactivity and fear – amygdala – had decreased gray matter density. This accounts for the feeling of peace as there is no fear.[5]

Meditation was found to increase the activity of the neocortex and decrease the activity of the limbic system of which the amygdala is a part, thus reducing its hold on our response. Meditation training was also found to reduce right amygdala activity during negative emotion processing.[6]

Meditation has already demonstrated innumerable benefits for physical health, and now, the latest research is able to show the evidence of its positive impact on mental health. This probably is the next step in the evolution of Homo sapiens.

Vijayalakshmi PernenkilSparsha Psychiatric Clinic, Vijayawada, Andhra Pradesh, India

Address for correspondence: Dr. Vijayalakshmi Pernenkil, Sparsha Psychiatric Clinic, Vijayawada, Andhra Pradesh, India.

E‑mail: [email protected]

1. World Health Organization. 130th session provisional agenda item 6.2. Global Burden of Mental Disorders and the Need of a Comprehensive, Coordinated Response from Health and Social Sectors at the Country Level. World Health Organization; 1 December, 2011.

2. Hall JE. Guyton and Hall: Textbook of Medical Physiology. 12th ed. Philadelphia: Saunders, Elsevier; 2011.

3. Goleman D. Emotional Intelligence. New York: Bantam Publishers; 1996.

4. Wang DJ, Rao H, Korczykowski M, Wintering N, Pluta J, Khalsa DS, et al. Cerebral blood flow changes associated with different meditation practices and perceived depth of meditation. Psychiatry Res 2011;191:60-7.

5. Hölzel BK, Carmody J, Vangel M, Congleton C, Yerramsetti SM, Gard T, et al. Mindfulness practice leads to increases in regional brain

Original ArticleEditorial

Pernenkil: Meditation

2 Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018

gray matter density. Psychiatry Res 2011;191:36-43.6. Leung MK, Lau WK, Chan CC, Wong SS, Fung AL, Lee TM, et al.

Meditation-induced neuroplastic changes in amygdala activity during negative affective processing. Soc Neurosci 2018;13:277-88.

How to cite this article: Pernenkil V. Meditation – The next step in evolution. Arch Ment Health 2018;19:1-2.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Access this article onlineQuick Response Code:

Website:www.amhonline.org

DOI:10.4103/AMH.AMH_20_18


Stem cell therapy role in neurodegenerative disordersPasam Ravisankar, Koppineedi Dhanavardhan1, Kompella Prathyusha1, Kattula Rao Vinay Rajan2

Department of Psychiatry, Konaseema Institute of Medical Sciences & Research Foundation, Amalapuram, 1Department of Pharmacy Practice, Vikas Institute of Pharmaceutical Sciences, Rajahmundry, East Godavari,

2Dr. NTR Vaidya Seva Trsust, Government of Andhra Pradesh, Guntur, Andhra Pradesh, India

INTRODUCTION

Stem cell-based therapies hold promise for the treatment of human illness. Each of the five sorts of human stem cells (embryonic, epithelial, biological process, neural, and mesenchymal[1]) has received appreciable attention from the scientific community for doubtless therapeutic properties. Stem cells are those cells that have the ability to continuously divide and differentiate into various other kinds of cells and tissues. There are three types of stem cells based on the differentiation potential; Totipotent cell has the power to create an organism alone, pluripotent cells can be converted into all cell types, and

multipotent cells can be converted into cell types in their own tissues.[2] Neurons and interstitial tissue cells are generated from stem cells such as embryonic stem (ES) cells, elicited pluripotent stem cells, mesenchymal stem cells and neural stem (NS) cells.[3,4] Thus, stem cell therapy might be beneficial in patients with neurodegenerative disorders.

RESULTS

Diagnostic knowledge confirmed that transplanted NS/neural precursor cells (NPCs) may exert a “bystander”

Cellular therapies represent a new frontier in the therapy of neurological diseases. Earlier, regeneration of neurons has been admitted as an impossible event. Thus, neurodegenerative disorders (e.g., Alzheimer’s disease, Parkinson’s disease, and multiple sclerosis), vascular events (e.g., stroke), and traumatic diseases (e.g., spinal cord injury) have been identified as incurable diseases. Later on, tissue reparative and regenerative potential of stem cell researches for these disorders drew attention of scientists to replacement therapy. Now, there are hundreds of current clinical and experimental regenerative treatment studies. One of the most popular therapies is cell transplantation. Transplanted neural stem/precursor cells protect the injured central nervous system using a variety of articulated mechanisms, a mode of action named ''therapeutic plasticity,” encompassing both bystander effects (immunomodulation and enhancement of endogenous repair mechanisms) and cell replacement. An extensive search was made using PubMed, Scopus, and Google Scholar using the following search terms: stem cells, neurodegenerative disorders, Alzheimer’s disease, and stem cell therapy. In this review, we presented the possible benefits of stem cell therapy in neurodegenerative disorders.

Keywords: Alzheimer’s disease, neurodegenerative disorders, neuronal precursor cells, Parkinson’s disease, stem cells

Abstract



DOI:10.4103/AMH.AMH_10_18

Address for correspondence: Dr. Kattula Rao Vinay Rajan, Dr. NTR Vaidya Seva Trust, Government of Andhra Pradesh, Behind Hero Gautam’s Hero Showroom, Chuttugunta, Guntur, Andhra Pradesh, India. E‑mail: [email protected]

How to cite this article: Ravisankar P, Dhanavardhan K, Prathyusha K, Rajan KR. Stem cell therapy role in neurodegenerative disorders. Arch Ment Health 2018;19:3-8.


For reprints contact: [email protected]

Review Article

Ravisankar, et al.: Stem cell therapy and neurodegenerative disorders


neuroprotective impact and identified a series of molecules – for example, immunomodulatory substances, neurotrophic growth factors, stem cell regulators as well as guidance molecules – whose in-situ secretion by NPCs is temporally and spatially orchestrated by environmental needs. An improved understanding of the molecular and cellular mechanisms sustaining this “therapeutic plasticity” has its importance for outlining crucial aspects of the bench-to-beside translation of NS cell therapy.[5] Continued Phase I/II clinical trials will explore the safety and efficacy profile of the stem cells, while, on the other hand, new cellular sources are being developed by cellular reprogramming.[6]

Stem cell therapy in neurologic disordersNeurologic diseases are caused by a loss of neurons and interstitial tissue cells within the central nervous system or peripheral nervous system.[7] Effective treatment of those neurologic diseases is presently not possible. Stem cell therapy may be a promising treatment possibility for these neurologic diseases.[8] To produce promising benefits and for clinical transplantation, stem cells should possess some essential properties such as the ability of clonal propagation in vitro to ensure homogeneity, genetic stability at high passage, integration within the host brain following transplantation, migration and engraftment at the sites of damage, and the lack of undesirable effects.[9,10] The Significance of stem cell therapy in various neurodegenerative disorders is discussed below [Figure 1].

Stem cells – Huntington’s diseaseHuntington’s disease (HD) may be a fatal, balky disorder that is characterized by chorea (excessive spontaneous movements) and progressive dementedness. It is caused by the death of neurons within the basal ganglion.[11] Stem cell therapy aims to preserve or restore brain function by acting at exchange and protective striatal neurons. Stem cell-based approaches are still in their infancy, and the

reconstruction of striatal neural activity has not been observed in animals.[12] However, human neuronal stem cells deep rooted into the brains of rats were recently found to cut back motor impairments in experimental HD through trophic mechanisms.[13] At present, quite neuronic replacement, use of stem cells for the neuroprotection to stop disease progression, appears an additional realizable clinical goal in HD.[14]

Parkinson’s diseaseThe hallmark of Parkinson’s disease (PD) is gradual loss of nigrostriatal dopamine-containing neurons; however, degeneration additionally happens in systems of nondopaminergic neurons.[15] The most common symptoms are rigidity, poorness of movement (bradykinesia), tremor, and bodily property of instability. Current therapies focus on the oral administration of L-dopa, dopamine receptor agonists, and on deep-brain stimulation in the subthalamic nucleus. However, these treatments are effective for a few symptoms but are associated with side effects. They might not stop the progression of the disease.[16] To be clinically competitive, a stem cell-based therapy should be long, ameliorate classical symptoms, and counteract disease progression.[17] Clinical trials of the transplantation of human dopaminergic neurons have shown that cell replacement will deliver major long improvement in some patients.[18] This favors the use of stem cells with potency to regenerate dopaminergic neurons isolated from interstitial cells, bone marrow, and human brain.[19,20] To make stem cell therapy work for PD,[21] dopaminergic neurons with the characteristics of neural structure must be produced in large numbers. For Dopaminergic neurons generated from human ES cells, survival after transplantation in animal models has been poor and needs to be markedly increased before clinical application. It will even be necessary to develop methods that hinder illness progression. One possible approach to prevent the death of existing neurons could be to transplant human stem cells engineered to express neuroprotective molecules such as glial-cell-line-derived neurotrophic factor (GDNF) [Figure 2].[22]

Amyotrophic lateral sclerosisIn amyotrophic lateral sclerosis (ALS), dysfunction and degeneration of motor neurons occur not only in the spinal cord (lower motor neurons) but also in the cerebral cortex and brain stem (upper motor neurons).[23] Muscle weakness progresses rapidly and death happens in a couple of years.[24] Stem cell therapy should restore or preserve the function of each higher and lower motor neuron, and new neurons should become integrated into the existing neural circuitries. Recent reports have shown its potential to get lower motor neurons in vitro from stem cells of Figure 1: Pathways of various neurodegenerative diseases


Archives of Mental Health | Volume 19 | Issue 1 | January-June 2018 5

assorted sources, as well as ES cells. Mouse ES cell-derived motor neurons establish purposeful synapses with muscle fibers in vitro and extend axons to ventral roots during transplantation into adult rats.[25] However, integration of these cells into the existing neural circuitries and restoration of motor function are not yet established;[26] whereas neuronic replacement in ALS patients seems a distant goal, using stem cells to stop motor neurons from degeneration may be an additional realistic and short-term clinical approach. This prospect is supported by studies showing that human embryonic germ cells delivered into the liquid body substance of rats with neuron injury will migrate into the funiculus and induce motor recovery, most likely through neuroprotection. The efficaciousness of this approach may well be improved by genetically modifying the stem cells to secrete molecules that promote neuron survival.[27] For instance, a study showed that human cortical progenitors that were engineered to express GDNF survived implantation into the spinal cords of ALS rats and released the neurotrophic factor.[28]

StrokeStroke is caused by blockage of artery, resulting in focal anemia; loss of neurons and interstitial tissue cells; and motor, sensory, or psychological feature impairments.[29] No effective treatment to promote recovery exists, so a therapy that produce even minor improvement would be valuable. Transplanted cells from different sources, such as fetal brain, neuroepithelial or teratocarcinoma cell lines, bone marrow and umbilical cord, have yielded some improvement in animals and, in one clinical trial, in humans affected with stroke.[30] In most cases, the grafts have acted by providing organic process factors that enhance cell survival and function. However, for stem cell therapy to be of major clinical worth, human cells ought to be able to replace dead neurons, remyelinate axons, and repair broken neural cells.[31] As a primary step toward this goal, human NS cells were transplanted into the brains of stroke-damaged rats, leading to the migration of latest neurons toward the ischemic lesion.[32] Other studies showed that monkey

ES-cell-derived progenitors transplanted into the brains of mice after stroke differentiated into various types of neuron and glial cell, re-established connections with target areas, and led to improved motor function.[33] The therapeutic efficaciousness of such methods may well be improved more by genetically modifying the stem cells: as an example, by overexpressing associate-degree anti-apoptotic gene. Interestingly, the stroke-damaged adult placental brain has some capability for neuronic replacement from its own NS cells.[34] For several months after a stroke, NS cells will generate new striatal neurons that migrate to the location of damage. It is currently vital to ascertain whether or not endogenous maturation will contribute to purposeful recovery after stroke. Regeneration of animal tissue neurons is going to be the premise for purposeful improvement in most stroke-damaged brains. Effective therapies can rely on methods to extend the survival of the new neurons and to boost their incorporation into reorganizing neural circuitries.

Alzheimer’s diseaseAlzheimer’s disease (AD) is characterized by neuronic and conjugation loss throughout the brain, involving the basal prosencephalon cholinergic system, amygdala, hippocampus, and several other animal tissue areas. Patients’ memory and psychological feature performance is increasingly impaired; they develop dementia, and square measure seemingly to die untimely. Current therapies, such as treatment with acetylcholinesterase inhibitors to boost cholinergic function, offer solely partial and temporary alleviation of symptoms. The pathological changes seen in AD provide a particularly problematic scenario for cell replacement. Given the widespread and progressive injury within the brains of patients with AD, it is unlikely that the mechanisms for instructing transplanted NS cells to differentiate into new neurons are going to be intact. In theory, psychological feature decline caused by the degeneration of basal prosencephalon cholinergic neurons may well be prevented by the movement of cholinergic neurons generated from NS cells in vitro. But to provide long-lasting symptomatic benefit, this approach would require the existence of intact target cells within the patient’s brain, and these are highly likely to be damaged. However, stem cells will be genetically changed and have migratory capability during transplantation; they might be used for the delivery of things that may modify the course of the illness. In support of this approach, basal prosencephalon grafts of fibroblasts produce nerve protein that counteracts cholinergic neuronic death, stimulate cell function, and improve memory in animal models [Figure 3].

Figure 2: Stem cell transplant research – Parkinson’s disease



Multiple sclerosisMultiple sclerosis (MS) is caused by the inflammation-induced destruction of the sheath that surrounds axons, resulting in physical phenomenon deficits and a range of neurologic symptoms and, in some patients, major incapacity. Nerve fiber loss as a consequence of acute inflammation or chronic degenerative disorder is a vital reason for deterioration. Immunomodulatory treatment alone is not effective. Myelin-producing neuroglial ascendant cells are abundant in the adult human brain. Spontaneous remyelinating happens to varying degrees within the early stages of MS, and myelin-producing neuroglial ascendant cells can be a hope of choice in chronic demyelinated MS lesions. A vital space of analysis is that focused on finding ways to enhance remyelination from these cells and distinguishing the factors that cause a failure of cells to provide fat within the first place. To this end, one study[23] showed that astrocyte-derived hyaluronan accumulated in demyelinated lesions from MS patients and prevented the maturation of endogenous myelin-producing neuroglial ascendant cells. The transplantation of remyelinating cells represents another approach for treating fat loss in MS. Human adult and ES cell-derived myelin-producing neuroglial ascendant cells are shown to myelinate demyelinated mouse brain and funiculus during transplantation. However, a serious concern is that the inflammatory surroundings may destroy the transplanted myelin-producing neuroglial ascendant cells and inhibit their maturation. Immunological disorder and anti-inflammatory treatments may thus be necessary. Another downside is that the demyelinated MS lesions are distributed across multiple locations throughout the system. An efficient medical aid would force the deep-rooted myelin-producing neuroglial ascendant cells to migrate to those sites. Interestingly, during general administration in mice, NS cells migrate to inflammatory demyelinating lesions and some become myelin-producing neuroglial ascendant cells and remyelinated axons. Most cells remained dedifferentiated and suppressed pro-inflammatory mechanisms.

Spinal injuriesSpinal injuries interrupt ascending and drizzling nerve fiber pathways and cause a loss of neurons and interstitial tissue, inflammation, and degenerative disorder.[35] The lesions cause a loss of movement, sensation, and involuntary management below the location of injury. There is no cure, and the commonest current treatment of high-dose methylprednisolone is of questionable worth. The transplantation of stem cells into injured spinal cord can lead to functional benefits, mainly through trophic factor secretion or the remyelination of spared axons.[36] A recent study showed that human NS cells deep rooted into broken mouse funiculus generated new neurons and oligodendrocytes, resulting in movement recovery.[37] However, unless transplantation is monitored, there is a risk of development of undesirable effects. Astrocytic differentiation and aberrant axonal sprouting after NS-cell implantation into injured rat spinal cord can cause hypersensitivity to stimuli that are not normally painful.[38] Perhaps the most realistic short-term clinical goal is to use stem cells for remyelination, which probably occurs to some degree after lesions from endogenous oligodendrocyte precursor cells. One study rumored that during NS cell implantation into compromised funiculus in rats, there was a correlation between the amount of graft-derived oligodendrocytes, the quantity of fat, and therefore the extent of desired recovery. Another study published that transplanted oligodendrocytes from human ES cells may myelinate the injured rodent spinal cord and improve motor function.

CONCLUSION

It might be premature to use stem cells to treat neurologic disorders. However, steady progress supports the hope that stem cell-based therapy helps to revive the function of brain and funiculus. For every disease, it is currently crucial to develop a road map that defines the scientific and clinical advances required for stem cells to succeed in the clinic. Before initiation of stem cell therapies to patients, one must be able to control the proliferation and differentiation of stem cells into specific cellular phenotypes and to prevent tumor formation. Moreover, the efficaciousness of stem cells and their mechanisms of action should be demonstrated in animal models, with pathology and symptomatology resembling the disorders in humans. Even so, it may be difficult to correlate data obtained in animals to humans because of species differences in the degree of neuronal plasticity and an incomplete knowledge of disease mechanisms. One must understand how to

Figure 3: Stem cell treatment for Alzheimer’s disease



influence the pathological tissue environment, including inflammatory and immune reactions, to allow efficient repair. Exciting the neurobiological mechanisms might be the clinical usefulness of stem cells; however, it must be remembered that significance of stem cell therapy will be determined by their ability to provide safe, long-lasting, and substantial improvements in the quality of life of patients with neurological disorders.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

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11. Strecker RE, Sharp T, Brundin P, Zetterström T, Ungerstedt U, Björklund A, et al. Autoregulation of dopamine release and metabolism by intrastriatal nigral grafts as revealed by intracerebral dialysis. Neuroscience 1987;22:169-78.

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13. Kordower JH, Charles V, Bayer R, Bartus RT, Putney S, Walus LR, et al. Intravenous administration of a transferrin receptor antibody-nerve growth factor conjugate prevents the degeneration of cholinergic striatal neurons in a model of Huntington disease. Proc Natl Acad Sci U S A 1994;91:9077-80.

14. Stenman J, Toresson H, Campbell K. Identification of two distinct progenitor populations in the lateral ganglionic eminence: Implications for striatal and olfactory bulb neurogenesis. J Neurosci 2003;23:167-74.

15. Davies SW, Turmaine M, Cozens BA, DiFiglia M, Sharp AH, Ross CA, et al. Formation of neuronal intranuclear inclusions underlies the neurological dysfunction in mice transgenic for the HD mutation. Cell 1997;90:537-48.

16. Wallén AA, Castro DS, Zetterström RH, Karlén M, Olson L, Ericson J, et al. Orphan nuclear receptor Nurr1 is essential for Ret expression in midbrain dopamine neurons and in the brain stem. Mol Cell Neurosci 2001;18:649-63.

17. Piccini P, Lindvall O, Björklund A, Brundin P, Hagell P, Ceravolo R, et al. Delayed recovery of movement-related cortical function in Parkinson’s disease after striatal dopaminergic grafts. Ann Neurol 2000;48:689-95.

18. Lindvall O, Brundin P, Widner H, Rehncrona S, Gustavii B, Frackowiak R, et al. Grafts of fetal dopamine neurons survive and improve motor function in Parkinson’s disease. Science 1990;247:574-7.

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Mental Health Care Act 2017: Review and upcoming issuesPrasanna Kumar Neredumilli, V. Padma, S. Radharani

Department of Psychiatry, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India.

INTRODUCTION

Legislation plays a vital role in the treatment of persons suffering from mental disorders. Insight of illness may not be present in majority of mental disorders when compared to physical illness and the law guides for treatment in a proper direction. In India, different legislations have come. Mental Health Care (MHC) Act 2017 has passed through different timelines. It was passed and approved by Parliament and got assent by the president in April 2017 and eventually come into force from May 29, 2018. Earlier with the Mental Health Act (MHA) 1987, there was a start for human approach for treating mental disorders with provisions for human rights but without emphasis on issues like consent. Provisions for voluntary admissions and special circumstances were started. As it involved the department of police and honorable courts in admission and discharge procedures, it had failed to remove virtual criminal flavor on admission of patients with mental illness. There was no time frame for maximum period of inpatient hospitalization for persons admitted involuntarily with exception of special circumstances.

Management of persons suffering from mental illness was being done mostly in inpatient settings in hospitals and closed wards, and they were at disadvantage position as there were chances for vulnerability and human rights violation. These violations in human rights could lead to further psychiatric issues such as depression and anxiety.

Convention on the rights of persons with disabilities (CRPD) was passed by the United Nations (UN) General Assembly in 2006 and was signed and ratified by India in 2007 and made India eventually responsible for the revision of disability laws in India and introduction of MHC Act[1] 2017. MHC act is published in the spirit of UNCRPD with human rights of person with mental illness (PMI) and review board acting as the backbone on the fulcrum of mental capacity.

As per MHC act 2017, mental health professional (MHP) includes psychiatrist, professionals having a postgraduate degree including Ayurveda in Mano Vigyan Avum Manas Roga or Homoeopathy in Psychiatry or Unani in Moalijat (Nafasiyatt) or Siddha in Sirappu Maruthuvam,

Mental Health Care (MHC) Act 2017 is published in the Gazette by Government of India. It is aimed at strengthening human rights of persons with mental illness. Changes such as advance directive and nominated representative are new, and review boards and responsibilities of government are clearly emphasized. The objective of this article is to give an overview of MHC act 2017 and its upcoming issues while implementing it.

Keywords: Advance directive, Mental Health Care Act 2017, nominated representative

Abstract



DOI:10.4103/AMH.AMH_8_18

Address for correspondence: Dr. Prasanna Kumar Neredumilli, Department of Psychiatry Government Hospital For Mental Care, Visakhapatnam, Andhra Pradesh, India. E‑mail: [email protected]

How to cite this article: Neredumilli PK, Padma V, Radharani S. Mental health care act 2017: Review and upcoming issues. Arch Ment Health 2018;19:9-14.



Review Article

Neredumilli, et al.: Review of mental health care act 2017


and also a professional registered with the concerned State Authority under Section 55 (clinical psychologists, mental health nurses [MHNs], and psychiatric social workers) and they will become eligible for assessing mental capacity and eventually for admitting them as inpatient in independent admissions as per the 2017 act. Mental health establishment (MHE) includes inpatient establishments of all health establishments including all other medical treatment modalities as specified by act for care of PMI excluding residential places. This makes even the multispecialty hospitals and general hospitals under the purview of the act for registration as MHE and these hospitals may not register due to unnecessary fears which may lead to decreased treatment options for PMI. The Indian Psychiatric Society has given representations to government to remove general hospital from registration as MHE, but the Government did not consider it. The act highlighted the importance of clause “meant for care” for PMI, and this is reflected for defining places like sheltered accommodation for not specifying MHE registration as seen in draft rules.

Even though it may appear that the MHCA 2017 may not be applicable to MHP practicing at outpatient services or establishments without registration, there are some sections of the act they too have to follow. These include advance directive (AD), aspects of confidentiality, rights to access basic medical records by patients, and provisions of treatment procedures such as electroconvulsive therapy (ECT), psychosurgery, seclusion, and emergency treatment.

The definition of mental illness encompasses in broader sense and is not equated with unsoundness of mind and has to be determined by international classification of diseases (ICD 10) and not by the past treatment or hospitalization. The broader definition of mental illness may lead to persons having milder mental illness to be branded as having mental illness leading to stigma and further may affect the persons for accessing treatment. The clause “mental conditions associated with abuse of alcohol or drugs” signify that deaddiction centres may come under the purview of act unless they specify that they give care for only substance abuse persons.

If a person (including PMI) is able to understand the information for decisions admission, treatment or personal assistance or appreciate reasonably foreseeable consequences of decision or communicate the decision by means of speech, expression or gesture, then he is deemed to have capacity to make decision regarding MHC treatment and can write AD and is eligible for admissions

on independent basis. Persons suffering from neurotic disorders and psychotic disorders with the exception of chronic disorganized psychosis,delirium,dementia and organic psychosis may have capacity and may be considered under this act and eventually has to be admitted on independent basis. The clause “mental capacity” segregates PMI and this segregation may raise doubts whether MHC Act is in true spirit of UNCRPD or not. There needs to be further information by the guidance document of the expert committee.

ADVANCE DIRECTIVE

A person who is not a minor having mental capacity can write directive as specified by mental health authority regarding his intention for the way he/she wishes to be cared for and not to be cared for and can appoint nominated representative (NR) in spite of whether he/she is having past illness or had treatment for mental illness. NR has to sign if name is mentioned in AD and also signatures by two witnesses have to be taken. In case PMI comes alone and has not written or given AD, he/she may be given treatment after consent and may be admitted as in patient admission. If PMI wants to be treated at corporate hospital only and relative is not in a financial position to give treatment, then relative or caregiver or MHP may apply to board for review of AD. PMI suffering from psychosis may perceive that harm will be done by known persons like family members or unknown persons and may write AD and thereby cannot get treatment. In these situations also, MHP or relative may approach the board for review of AD. The provision of AD may not be aware in illiterate persons and implementation of these sections by them is debatable. The past literature also reveals that implementation of AD has been difficult.[2] However, there are some favorable aspects of AD for MHP and these include nonapplicability of AD in emergency treatment, duty of PMI or NR to make access of AD, and MHP not liable if not given copy of AD or for unforeseen consequences of valid AD.

NOMINATED REPRESENTATIVE

Psychiatric illness may cause burden to caregivers and in turn can affect the care of PMI. The MHC act 2017 has given sections for support of PMI by way of NR. The NR can be a relative or caregiver, suitable person appointed by board, or person of organization registered under societies registration act and may be revoked by board. NR shall not be minor and has to give consent in writing to MHP. NR can seek information of diagnosis and treatments, rehabilitation, planning discharge, application for admission, and give consent if required.



The high caregiver burden with mental disorders can sometimes lead to orphanage of PMI leading to wandering aimlessly and NR could support in this issue. In situations where the PMI has not written NR, may be due to unawareness of the act, then relative or caregiver can be deemed to be considered as NR and if not willing then the board appoints a suitable person. In admission where PMI is voluntarily admitted as independent admission, NR is not necessary to stay with him. In cases where family is included in delusional rubric of patient, there are chances of appointing other person who may not be having good intent as NR and the role of NR in this type of cases may not be appreciable. The Indian Psychiatric Society has highlighted that AD and NR are not patient friendly, but the government has not considered the representation.

The state shall maintain a panel of trained caregivers [3] whose antecedents are verified by police and having them will help family members to attend to their personal duties. There are rules for providing emergency service number available to family caregivers at every district headquarter to call for help. Special care shall be taken by the government regarding vulnerable caregivers such as single, adolescent, and elderly caregivers.

HUMAN RIGHTS

Human rights are given major importance and includes the right to access MHC treatment, cost affordability and good-quality mental health services, accessibility, and without discrimination. The facilities include acute care and outpatient and inpatient treatment.

There are sections in MHC act 2017 for PMI to have a dignified life, protection from cruel treatment, self-hygiene, privacy, proper clothing, pay for work, living in community, adequate food, no tonsuring, no force of uniforms, emergency and ambulance services, mobile, e-mail facilities, and free legal services. Insurance for mental disorders and treating the PMI according to International guidelines. There are provisions for not separating woman and child below 3 years of age and if separated for more than 30 days it should be approved by authority. This act has given significance for rights of PMI receiving inpatient treatment and grossly neglected the rights of PMI of community. Unemployment is reported to be significant in persons with mental disabilities[4] when compared to other disabilities, and this issue is not give importance in this act.

Government has to take measures and they include allocating budget in terms of adequacy,priority,equity

and legal aid. It shall support establishments for PMI to live in less restrictive community and in family. The other measures include conducting programmes for suicide and stigma prevention. Measures for increasing human resources of mental health services were mentioned. However, feasibility and practical implementation in real scenario may be debatable. Regarding confidentiality, information of PMI has to be made available only to NR and MHP and has to be protected from others except in threat to life. In cases of NR who sometimes may not be a family member, the availability of confidential information can affect the privacy of information of PMI.

The duties of central and state Government includes establishment of halfway homes, sheltered accommodation, and Supported accommodation, hospital and community based rehabilitation services. The supported accommodation is for those who have own or rented accommodation without caregiver, and they will get domiciliary care at doorstep.

The government shall start child mental health services, provide psychotherapies like cognitive behavior therapies and also include mental health in school syllabus. There shall be counselor in secondary schools. Elderly PMI shall have quality mental health services.

The major importance of human rights in MHCA 2017 will eventually lead changes in aspects of caring PMI and may include upgrade facilities in sanitary and environmental conditions, making preventive measures to all forms of abuse to PMI, facilities for caring both mother and child, maintaining records and to release information to PMI or NR or board if needed, aspects of confidentiality and facilities of telephones or e-mail, and providing details of board and free legal services.

CENTRAL MENTAL HEALTH AUTHORITY AND STATE MENTAL HEALTH AUTHORITY

Central Mental Health (CMH) Authority comprises 20 members with 3-year term and maximum age of 70 years and have to meet every 6 months and may be joined by televideo conference. CMH comprises of secretary, joint secretaries of department of health and family, director general of health services, director of central institutes, mental health professional with 15 years experience, psychiatric social worker, clinical psychologist, MHN, two members of PMI, caregivers, persons of nongovernmental organization (NGO), and persons relevant to mental health. CMH shall register MHE, have quality norms of MHE, supervise MHE, maintain national register of MHP, train MHP, and advise central government on MHC.



State mental health authority shall meet not <4 times a year and comprises principal secretary, joint secretary, head of mental health institute, eminent psychiatrist, MHP, psychiatric social worker, clinical psychologist, MHN, two members of PMI, caregivers, and persons of NGO. The Indian Psychiatric Society has requested to include professional associations of psychiatrists in authorities, the government has not considered.

MENTAL HEALTH ESTABLISHMENT REGISTRATION

MHE registered as clinical establishment can apply for registration with fees as prescribed, after fulfilling standards specified by authority and within 10 days without inquiry can get provisional registration having validity for 12 months. This is followed by publishing online or print of all particulars of MHE by authority within 45 days. MHE has to submit the evidence for minimum standards within 6 months from the date of such standards specified by the authority. The authority shall give public notice for filing objections, and MHE has to submit evidence and if there are no objections communicated to MHE, then it is deemed to get permanent registration. The authority shall conduct audit of all registered MHE every 3 years. In case if MHE fails in aspects of human rights or persons of MHE had committed an offence then the authority may issue showcause, and at last, registration may be canceled. MHE has to display certificate, website, phone, and address of board. Among the members of AUDIT, there shall be psychiatrist and one a representative of an organization for PMI.

MENTAL HEALTH REVIEW BOARD

Mental Health Review Board will be set up mostly in every district as per the CMH recommendation and will be for a term of 5 years. Review board members can be holding office up to the maximum age of 70 years and members comprise Honourable District Judge (retired also considered), representative of district collector, psychiatrist, medical practitioner, and two persons can be either PMI or caregivers or persons of NGO. The proceedings are deemed to be judiciary proceedings as per the IPC 193, 219, 228 and also shall be held in camera. They have to dispose application given by MHP for supported admissions within 7 days for Section 89, 21 days for Section 90, and 90 days for others. Their remuneration and salaries will be met by central authority grants. The functions of board includes registering and reviewing AD, appoint NR, decide objections against MHP and MHE, deciding for nondisclosure of PMI information, visit jails, protect human rights.

Mental illness comprises different disorders and, in some cases of delusional disorder where the delusion is systematized, it will be difficult for nonpsychiatrists to recognize this as mental illness, and in these types of cases psychiatrist has to give extra effort as he/she is the only person of board having adequate knowledge for mental illness and has to convince the other board members. As the board will be set up at district level or areas specified by authority, it will become difficult for the PMI and MHP staying in remote areas for access of board and it may lead to delay in treatment.

ADMISSION AND TREATMENT

Voluntary admission as per the MHA 1987 is changed as independent admission (Section 86 of MHC act 2017 and Section 17 of 1987) and refers to admission of PMI who has the capacity to make MHC and treatment decisions or requires minimal support in making decision and has mental illness of severity requiring admission, likely to benefit or understand the nature and purpose of admission. Informed consent has to be taken. The person admitted in this section may himself be discharged even without the consent of medical officer. MHP includes psychiatric social worker and mental health nurse, and they may admit PMI in MHE as per the act. But whether they will be having considerable experience in assessing capacity for treatment decisions is a matter of debate. In cases of PMI not able to understand the purpose or nature of treatment resulting in not accepting the treatment and also unable to take care himself, violent, then the PMI has to be admitted as supported admission (Section 89 of MHC act 2017 and Section 19 of MHA 1987) after application given by NR provided PMI shall not be readmitted within 7 days. It is followed by examination by psychiatrist and MHP and if the findings are as per this section of the act, then PMI can be admitted for a maximum period of 30 days after taking AD and it has to be reported to board. Consent can be obtained from NR and the consent from PMI has to be reviewed every 7 days. If admission requires more than 30 days or readmission within 7 days (section 90), they should be examined by two psychiatrists and can be admitted for a maximum period of 90 days if they satisfy norms as per this section of the act and have to inform the board for permission, taking account of AD and consent should be reviewed fortnightly along with planning for community-based treatment. While the PMI is receiving treatment as per supported admission and in case if NR wishes for discharge of PMI then he has to apply to the Board. In this section, the treating psychiatrist should be cautious for checking consent and record notes and intimating the board at regular intervals as specified.



If admission is extending beyond 90 days, it can be extended for 120 days at first instance and thereafter for 180 days each time after complying with the provisions of this section of act. Provisions for involuntary admission of PMI with disability/chronicity may not be in tune with UNCRPD, but in psychological disorders it is different as there may situations of harm or death of himself or others by PMI may eventually require these types of sections for safety and protection of PMI or others.

PMI who are wandering, not capable of taking care of himself can be taken under protection by police officer and after informing NR they may produce before public health establishment (100 of MHC Act 2017, 23 of MHA 1987). If he / she had mental illness then PMI has to be treated as per the provisions of act and in case if he/she is not eligible as per independent admission then has to be examined by psychiatrist and MHP as per section 89. In case of PMI is ill treated or neglected then the police officer may produce for 10 days in MHE and after assessment the treatment of PMI has to be followed as per the provisions of the act (101,102 of MHC Act 2017, 25 of MHA 1987). In case of prisoners act, Air force act, Army act, Navy act and code of criminal procedure can be treated at psychiatric ward in medical wing of prison and when there is no facility of psychiatric ward they can be transferred to MHE after permission from board (103 of MHC Act 2107, 27 of MHA 1987). As per the rules under section 121 of MHC Act there shall be screening for all inmates of prison during the time of entry including Mental status examination, urine testing for common drugs of abuse, protocols for dealing prisoners with suicidal risk, counselling for stress and prison after care services. When proof of mental illness is challenged during the judicial proceedings of honourable court then the honourable court may send to board for scrutiny (105 of MHC Act 2017,26 of MHA 1987).

In admission of minor (Section 87 of MHC act 2017 and Section 16 of MHA act 1987), NR of minor has to give application to medical officer and after being examined by two psychiatrists or psychiatrist and medical officer or psychiatrist and MHP and if they are satisfied as per the norms of this section then the minor can be admitted in separate accommodation from adults, consent taken from NR and informed and informed to board. If admission lasts more than 30 days, it should be again informed to the board. In case of minor girl and NR is male, a female attendant should be appointed by NR.

Emergency treatmentMedical treatment can be given for mental illness by registered medical practitioner to a PMI either at MHE

or at community for a maximum period of 72 h with informed consent of NR to prevent death or irreversible harm to health of person or person inflicting serious harm to himself or person causing serious damage to property. Electroconvulsive therapy (ECT) shall not be used as form of treatment in this section of emergency treatment. There is provision of transportation of PMI to nearest MHE.

ECT without anesthesia, sterilization of PMI, and chained procedures shall not be performed. PMI shall not be kept in seclusion and only physical restraint should be used to prevent imminent harm and to be recorded in medical notes. Board permission has to be taken for ECT in minors and in case of psychosurgery.

ECT is effective treatment and has been using since long time with less side effects. Imposing ban on unmodified ECT may lead to removal of efficacious treatment for the PMI of remote distant places where anesthetist may not be available. ECT is a lifesaving option in emergency psychiatric situations like suicide and removing its role cannot be replaced. The Indian Psychiatric Society has highlighted the importance of unmodified ECT, but the Government has not considered.

There are provisions for psychiatrist responsibility for PMI care and future treatment in consultation with PMI or NR. But for PMI who are not interested to continue medication after discharge or stopped treatment after going into community, there are no alternative provisions to deal with them. Provisions for rehabilitation and managing the assets/property of PMI are not given in this act. The research should be conducted with informed consent from PMI, state authority, and institutional ethics committee.

If a person contravenes the act there are fines ranging from imprisonment of 6 months, ten thousand rupees to 2 years, five lakh rupees. There is provision for the central government for control over CMH. In cases of difficulties that arise in giving effect to the act, the central government may publish orders for making provisions not consistent with act. In view of communication and travel difficulties, there are provisions for Northeastern states regarding relaxations for time frames. As per the MHC act 2017, a person who commits suicide is presumed to have severe stress and shall not be punished. However, the clause “unless proved otherwise” of this section may make police to investigate for the cause. There will be no prosecution or legal proceedings against authority or board when done in good faith. However, relaxations for legal proceedings done in good faith were given to authorities and board but not to MHP and other personnel directly involved in treatment.



The future favorable ray of hope for MHPs includes guidance document by expert committee on mental capacity as mental capacity is the backbone for AD and admission procedures. The other includes the power of central authority to modify or make additional regulations on AD after periodical review.

CONCLUSIONS

Mental health care Act 2017 is published with main emphasis of Rights of PMI in every aspect. MHP should give utmost importance to the Rights, address the transitions from MHA 1987 to MHCA 2017 including taking care to record and maintain case notes at every stage.



REFERENCES

1. The Mental Health Care Act 2017. Available from: http://www.prsindia.org/uploads/media/Mental%20Health/Mental%20Healthcare%20Act,%202017.pdf. [Last accessed on 2018 Jun 11].

2. Zelle H, Kemp K, Bonnie RJ. Advance directives in mental health care: Evidence, challenges and promise. World Psychiatry 2015;14:278-80.

3. Draft Rules and Regulations under Mental Healthcare Act, 2017. Available from: https://mohfw.gov.in/sites/default/files/Final%20Draft%20Rules%20MHC%20Act%2C%202017%20%281%29.pdf. [Last accessed on 2018 Jun 11].

4. Drew N, Funk M, Tang S, Lamichhane J, Chávez E, Katontoka S, et al. Human rights violations of people with mental and psychosocial disabilities: An unresolved global crisis. Lancet 2011;378:1664-75.


Clinical profile and changes in values of mean platelet volume among panic disorder patients

Sanjay Yalamanchili, Sai Kiran Pasupula, Raviteja ChilukuriDepartment of Psychiatry, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India

INTRODUCTION

Platelets could serve as a window into the brain as they may reflect biochemical changes in the brain in different psychiatric conditions.[1,2] Serotonin is an important factor in the pathophysiology of panic disorder, other anxiety disorders, and depression. Serotonin also has an important role in the regulation of vascular

tone and platelet aggregation.[3] Studies show that serotonin-mediated response of platelets enhances thrombogenesis in response to any disruption in blood vessel surfaces.[4,5] Platelet response and activation cannot be directly measured, so mean platelet volume (MPV) is used as a marker for the same. Several cardiovascular diseases such as acute myocardial infarction, ischemic

Context: The serotonin system is involved in the pathophysiology of anxiety disorders, but it is not practical to measure the serotonin levels inside the brain. Peripheral serotonin activity may reflect the central serotonergic function. An affordable and easy measure of peripheral serotonergic function is the mean platelet volume (MPV). Hence, MPV could possibly be used as a measure of central serotonergic function and hence could be a predictor of treatment outcome and response in panic disorder.Aims: This study aims to study the changes in MPV in patients with panic disorder with or without agoraphobia compared to healthy controls, thereby elucidating the relationship between panic disorder and MPV.Subjects and Methods: Patients (n = 65) who fulfilled the selection criteria and healthy controls (n = 65) were taken up for the study. Sociodemographic details and clinical variables were recorded in a special pro forma prepared for the study. Mini International Neuropsychiatry Interview-Plus was used for screening psychiatric morbidity. The diagnosis of panic disorder was made using the International Classification of Diseases-10 diagnostic criteria. Panic disorder severity scale and panic and agoraphobia scale were administered to all patients. MPV was assessed, and variations in MPV were studied between the groups.Statistical Analysis Used: Two-tailed independent sample t-test was used to compare the cases and controls. Results: It was observed that MPV values were higher for patients with panic disorder than healthy controls.Conclusion: MPV values were higher in panic disorder patients when compared to the healthy controls, so they could serve as predictors/indicators of treatment outcome and response in panic disorder.

Keywords: Anxiety disorders, mean platelet volume, panic disorder

Abstract



DOI:10.4103/AMH.AMH_4_18

Address for correspondence: Dr. Sai Kiran Pasupula, Department of Psychiatry, Katuri Medical College and Hospital, Guntur, Andhra Pradesh, India. E‑mail: [email protected]

How to cite this article: Yalamanchili S, Pasupula SK, Chilukuri R. Clinical profile and changes in values of mean platelet volume among panic disorder patients. Arch Ment Health 2018;19:15-8.



Original Article

Yalamanchili, et al.: Mean platelet volume in panic disorder


heart disease, and congestive heart failure are associated with increased MPV.[6-8] Selective serotonin reuptake inhibitors (SSRIs), which are commonly used in the treatment of panic disorder and depression, have been shown to cause decreased platelet activity in several recent studies.[9] This effect of SSRIs on platelet activity possibly points toward the role of a serotonergic mechanism in the pathophysiology of panic disorder.

There are only a few studies which have reported a relationship between MPV and panic disorder.[10] Hence, the aim of this study was to examine the varied clinical manifestations of patients with panic disorder and to study changes in MPV in patients with panic disorder, compared with age- and sex-matched healthy controls.

SUBJECTS AND METHODS

This nonrandomized case–control study was conducted in a tertiary care hospital. We selected the sample size based on previous studies and included 65 patients with a diagnosis of panic disorder and 65 healthy controls. In the sample, patient group was drawn from patients admitted to the psychiatry ward, either directly or transferred from other departments and the controls were selected from the general population (they were mostly hospital staff and attenders of patients admitted to other departments). Participants were selected sequentially, and no sampling was done.

Inclusion criteria• Panic disorder group • Age 18–60 years • Patients fulfilling the International Classification

of Diseases-10 (ICD 10)[11] diagnostic criteria for panic disorder, either with or without agoraphobia

• First-time admission and drug-naïve individuals.• Control group – age- and gender-matched healthy

individuals.

Exclusion criteria• Pregnant women• Individuals with comorbid psychiatric disorders• Individuals with comorbid medical disorders.

The study protocol was approved by the Institutional Ethics Committee. After explaining the purpose and design of the study, a written informed consent was obtained for participation from all individuals included in the sample. Sociodemographic and clinical variables were recorded in a specific pro forma prepared for the study. Mini-International Neuropsychiatry Interview-Plus[12] was used for screening psychiatric morbidity. The diagnosis

of panic disorder was made using the ICD-10 diagnostic criteria.[11] Panic disorder severity scale (scale)[13] and panic and agoraphobia scale (PAS)[14] were used to assess the severity of the disorder. For individuals in both groups, 5 ml of blood was drawn into vacutainer tubes containing 0.04 ml of 7.5% ethylene diamino tetraacetic acid (tri-potassium salt). Patient interviews and collection of blood samples were done at 8 AM for all individuals. MPV and platelet counts were measured using standardized equipment at the central laboratory of our hospital. Levels of 150,000–400,000/mm3 and 6.2–11.4 femtoliter (fL, a metric unit of volume equal to 10–15 L) were accepted as normal ranges for platelet counts and MPV, respectively.

Data were tabulated into a spreadsheet and IBM SPSS Statistics for Windows, Version 20.0 was used for statistical analysis of data. Two-tailed independent sample t-test was used to compare the cases and controls. P < 0.05 was considered as statistically significant.

RESULTS

Our sample had more females than males. The mean age in our sample was 32.55 ± 9.4 years. Most individuals with panic disorder were in the age group of 18–39 years. Rest of the demographic characteristics were as shown in Table 1. A majority were Hindus, literate, unmarried, unemployed, and belonged to the middle socioeconomic status (according to the modified Kuppuswamy scale for the classification of socioeconomic status).[15] Cases and controls did not differ much in these characteristics (P ≥ 0.05).

We had more cases with a diagnosis of panic disorder without agoraphobia (n = 39) than panic disorder with

Table 1: Sociodemographic dataParameter Study group, n (%) Control group, n (%)

GenderMale 23 (35) 24 (35)Female 42 (65) 43 (65)

ReligionHindus 50 (77) 46 (71)Christians 11 (17) 14 (21)Muslims 4 (6) 5 (8)

EducationLiterate 43 (66) 38 (58)Illiterate 22 (34) 27 (42)

Socioeconomic status

Low 27 (42) 22 (34)Middle 38 (58) 43 (66)

Marital statusMarried 25 (39) 29 (44)Unmarried 30 (61) 36 (56)

OccupationEmployed 31 (48) 32 (49)Unemployed 34 (52) 33 (51)



agoraphobia (n = 26). In this sample, the most prominent symptom of patients with a diagnosis of panic disorder with or without agoraphobia was chest pain (n = 53), followed by hyperventilation (n = 7), palpitations (n = 4), and least common was dizziness (n = 1) [Graph 1].

There was no significant difference in the platelet counts between groups. The MPV of the panic disorder group was 10.02 ± 0.37 fL and of the control group was 6.96 ± 0.99 fL. This difference (panic disorder > controls) was statistically significant (at P = 0.0001). The MPV values of the control groups and the panic disorder group were normal, but, values were significantly higher in the latter [Graph 2].

DISCUSSION

Currently, there is no convenient and cost-effective way of measuring central nervous system serotonergic function, but peripheral serotonergic function can be gauged easily by MPV. Several studies have reported that measures of platelet function can act as indicators of central serotonergic function.[1,16]

Our study is one of the first nonrandomized case–control studies which looks at a possible correlation between MPV and panic disorder at a tertiary care hospital.

In spite of being a cross-sectional study, our study sample gender characteristics were comparable to the past epidemiological studies which suggest that panic disorder is more common in women. This possibly also reflects the findings of past studies done on the prevalence of panic disorder, more so for the women.[17,18] We had more cases with a diagnosis of panic disorder without agoraphobia than panic disorder with agoraphobia, a finding consistent with findings of previous literature.[19]

MPV in the panic disorder group was significantly higher than in the control group. These findings emulate the past studies done on MPV and panic disorders.

Changes in the platelet parameters among the panic disorder individuals can be explained by the increased sympathetic activity among them. Few studies have shown that elevated MPV and heightened sympathetic activity are interrelated,[20-22] as are stress and panic disorder.[23] A relationship between panic disorder and a higher MPV is probably due to the involvement of the stress pathways.

The most common symptom of panic attacks found among the current sample was chest pain, and least number of the individuals suffered from dizziness. Panic attacks could lead to chest pain through mechanisms that directly affect coronary vasculature. Both autonomic activation and hyperventilation (via alkalosis) during panic attacks can lead to coronary artery spasm. In addition, panic attacks could provoke ischemic pain in patients with coronary disease by increasing myocardial oxygen demand through increases in heart rate and blood pressure mediated by the autonomic nervous system.[24,25] A study of 29 patients with syndrome X (chest pain, a positive exercise stress test, and normal coronary arteries) found that hyperventilation or mental stress reliably produced chest pain in 34% of patients.[26] The chest pain is associated with reduced coronary blood flow and is suggestive of the increased microvascular resistance.

Not all studies have found a consistent increase in the MPV in panic disorder patients. In a study done by Göğçegöz Gül et al.[10] there was a lower MPV in panic disorder patients, but no clear explanation could be found for the results which contradict our findings. They could only speculate that abnormal serotonin metabolism caused a decreased MPV.

Graph 2: Mean platelet volume comparison between cases and controls

Graph 1: Most prominent symptom in panic disorder with or without agoraphobia



CONCLUSION

In our study, we found that though MPV is not abnormal in panic disorder patients, it is significantly higher when compared with controls. MPV values could serve as predictors/indicators of treatment outcome and response in panic disorder. There is a need for multicentric studies with larger samples in this topic for more definitive evidence for MPV as a biomarker for panic disorder.

LimitationsThe current study sample is recruited from a single institute; therefore, results cannot be generalized to the entire population.



REFERENCES

1. Koudouovoh-Tripp P, Sperner-Unterweger B. Influence of mental stress on platelet bioactivity. World J Psychiatry 2012;2:134-47.

2. Camacho A, Dimsdale JE. Platelets and psychiatry: Lessons learned from old and new studies. Psychosom Med 2000;62:326-36.

3. Vanhoutte PM. Platelet-derived serotonin, the endothelium, and cardiovascular disease. J Cardiovasc Pharmacol 1991;17 Suppl 5:S6-12.

4. Lopez-Vilchez I, Diaz-Ricart M, White JG, Escolar G, Galan AM. Serotonin enhances platelet procoagulant properties and their activation induced during platelet tissue factor uptake. Cardiovasc Res 2009;84:309-16.

5. Galan AM, Lopez-Vilchez I, Diaz-Ricart M, Navalon F, Gomez E, Gasto C, et al. Serotonergic mechanisms enhance platelet-mediated thrombogenicity. Thromb Haemost 2009;102:511-9.

6. Huczek Z, Kochman J, Filipiak KJ, Horszczaruk GJ, Grabowski M, Piatkowski R, et al. Mean platelet volume on admission predicts impaired reperfusion and long-term mortality in acute myocardial infarction treated with primary percutaneous coronary intervention. J Am Coll Cardiol 2005;46:284-90.

7. Slavka G, Perkmann T, Haslacher H, Greisenegger S, Marsik C, Wagner OF, et al. Mean platelet volume may represent a predictive parameter for overall vascular mortality and ischemic heart disease. Arterioscler Thromb Vasc Biol 2011;31:1215-8.

8. Kandis H, Ozhan H, Ordu S, Erden I, Caglar O, Basar C, et al. The prognostic value of mean platelet volume in decompensated heart failure. Emerg Med J 2011;28:575-8.

9. Markovitz JH, Shuster JL, Chitwood WS, May RS, Tolbert LC. Platelet

activation in depression and effects of sertraline treatment: An open-label study. Am J Psychiatry 2000;157:1006-8.

10. Göğçegöz Gül I, Eryılmaz G, Ozten E, Hızlı Sayar G. Decreased mean platelet volume in panic disorder. Neuropsychiatr Dis Treat 2014;10:1665-9.

11. World Health Organization. International statistical classification of diseases and related health problems. 10th Revision (ICD-10). Geneva: World Health Organization; 1992.

12. Lecrubier Y, Sheehan D, Weiller E, Amorim P, Bonora I, Sheehan K, et al. The MINI international neuropsychiatric interview (MINI) a short diagnostic structured interview: Reliability and validity according to the CIDI. Eur Psychiatry 1997;12:224-31.

13. Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW, et al. Multicenter collaborative panic disorder severity scale. Am J Psychiatry 1997;154:1571-5.

14. Bandelow B. Assessing the efficacy of treatments for panic disorder and agoraphobia. II. The Panic and Agoraphobia Scale. Int Clin Psychopharmacol 1995;10:73-81.

15. Singh T, Sharma S, Nagesh S. Socio-economic status scales updated for 2017. Int J Res Med Sci 2017;5:3264-7.

16. Haroon E, Raison CL, Miller AH. Psychoneuroimmunology meets neuropsychopharmacology: Translational implications of the impact of inflammation on behavior. Neuropsychopharmacology 2012;37:137-62.

17. Yonkers KA, Zlotnick C, Allsworth J, Warshaw M, Shea T, Keller MB, et al. Is the course of panic disorder the same in women and men? Am J Psychiatry 1998;155:596-602.

18. McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res 2011;45:1027-35.

19. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE, et al. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2006;63:415-24.

20. Vizioli L, Muscari S, Muscari A. The relationship of mean platelet volume with the risk and prognosis of cardiovascular diseases. Int J Clin Pract 2009;63:1509-15.

21. Lande K, Gjesdal K, Fønstelien E, Kjeldsen SE, Eide I. Effects of adrenaline infusion on platelet number, volume and release reaction. Thromb Haemost 1985;54:450-3.

22. Thompson CB, Eaton KA, Princiotta SM, Rushin CA, Valeri CR. Size dependent platelet subpopulations: Relationship of platelet volume to ultrastructure, enzymatic activity, and function. Br J Haematol 1982;50:509-19.

23. Durmaz T, Özdemir Ö, Keleş T, Bayram NA, Akçay M, Yeter E. Platelets and sympathetic activity in MI. Turk J Med Sci 2009;39:259-65.

24. Argyle N, Roth M. The phenomenological study of 90 patients with panic disorder, part II. Psychiatr Dev 1989;7:187-209.

25. Klein DF. False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Arch Gen Psychiatry 1993;50:306-17.

26. Katon WJ. Chest pain, cardiac disease, and panic disorder. J Clin Psychiatry 1990;51 Suppl 5:27-30.


Caregiver burden in alcohol dependence syndrome in relation to the severity of dependence

R. S. Swaroopachary, Lokesh Kumar Kalasapati1, Sarath Chandra Ivaturi, C. M. Pavan Kumar Reddy2

Department of Psychiatry, SVS Medical College, Mahboobnagar, 1Department of Psychiatry, Bhaskar Medical College, 2Department of Psychiatry, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India

INTRODUCTION

Alcohol dependence is a maladaptive pattern of substance use for a period of 12 months, which is characterized by tolerance, withdrawal symptoms, loss of control, and craving.[1] The 1-year prevalence of alcohol abuse and dependence is estimated to be 6% or more.[2] General population surveys in India have reported a prevalence of alcohol use ranging from 1.15% to 50%.[3,4] Excessive partner alcohol use increased the risk for mental health disorders above and beyond significant sociodemographic

risk factors, including older age, poor education, fewer children in the home and lack of paid employment, with an associated population-attributable fraction of 17.5%. Partner violence and partner alcohol-related problems mediated the association of partner excessive alcohol use with women’s common mental health disorders.

Burden is defined as the presence of problems, difficulties, or adverse events which affect the life (lives) of the psychiatric patient’s significant others.[5] Families of patients

Background: Alcohol dependence is a maladaptive pattern of substance use for a period of 12 months, which is characterized by tolerance, withdrawal symptoms, loss of control, and craving. Burden is defined as the presence of problems, difficulties, or adverse events which affect the life (lives) of the psychiatric patient’s significant others. Objective burden is used to identify anything that occurs as a disrupting factor in family life owing to the patient’s illness while subjective burden refers to the feeling that a burden is being carried in a subjective sense.Aims: To compare the amount of burden among the caregivers with the severity of alcohol dependence in patients.Methodology: Severity of Alcohol Dependence Questionnaire is used to determine the severity of their condition in alcohol-dependent patients. Caregivers were administered Family Burden Interview Schedule to assess the burden experienced by them. The diagnosis of alcohol dependence syndrome is made in accordance to the ICD-10 criteria.Results: Severe burden is more seen in females, unemployed, in families where domestic violence is present.Conclusions: More severe is the dependence, more is the amount of burden experienced by the caregivers.

Keywords: Alcohol dependence syndrome, caregiver burden, severity of dependence

Abstract



DOI:10.4103/AMH.AMH_6_18

Address for correspondence: R. S. Swaroopachary, Department of Psychiatry, SVS Medical College, Mahboobnagar ‑ 509 001, Telangana, India. E‑mail: [email protected]

How to cite this article: Swaroopachary RS, Kalasapati LK, Ivaturi SC, Reddy CM. Caregiver burden in alcohol dependence syndrome in relation to the severity of dependence. Arch Ment Health 2018;19:19-23.



Original Article

Swaroopachary, et al.: Caregiver burden in alcohol dependence syndrome


with mental illness face stigmatization, long-term economical and emotional burden of taking care of the patient. Illness in the patient has an impact on the work, social relationship, and leisure activities of family members. This evokes different feelings in the family members, which can have an impact on the course and prognosis of the illness.[6]

Hoenig and Hamilton were the first to make a clear distinction between objective and subjective burden. Objective burden is used to identify anything that occurs as a disrupting factor in family life owing to the patient’s illness[7] while subjective burden refers to the feeling that a burden is being carried in a subjective sense.[8] Bhowmick et al. reported that the presence of individual with alcohol or drug dependence in the family affects various aspects of family such as leisure time activities, family and social relationships, and finances.[9]

Thus, an overall limitation of the preexisting research is the lack of simultaneous examination of different psychosocial risk factors and thereby, a limited understanding of the interrelationships between such factors in women’s poor mental health.

Aims1. To know the prevalence of alcohol dependence

syndrome in relation to the sociodemographic variables2. To assess the severity of alcohol dependence among

the patients3. To assess the caregiver burden among the primary

caregivers4. To compare the amount of burden among the

caregivers with the severity of alcohol dependence in patients.

METHODOLOGY

This is a cross-sectional hospital-based study. The study was conducted in the In-patient Department of Psychiatry, SVS Medical College and Hospital. This is a tertiary care hospital, providing specialist clinical care to Mahbubnagar and the adjoining districts. The present study was conducted for 6 months, i.e., from November 1, 2016 to April 30, 2017. The study sample was collected from patients admitted for alcohol dependence syndrome and their caregivers. Patients were selected consecutively. The study sample consisted of seventy patients diagnosed to have alcohol dependence syndrome and their respective caregivers.

Patients and their caregivers fulfilling selection criteria were approached and informed consent was obtained. Interview was carried out after 2 weeks to rule out the

possibility of the presence of withdrawal symptoms in alcohol-dependent patients.

Clinical and sociodemographic details of patients and their caregivers were collected using a semi-structured proforma. Severity of Alcohol Dependence Questionnaire[10] is used to determine the severity of their condition in alcohol-dependent patients. Caregivers were administered Family Burden Interview Schedule[11] to assess the burden experienced by them. Assessments were cross-sectional and nonblind. The diagnoses of alcohol dependence syndrome are made in accordance to the ICD-10 criteria.[12]

Inclusion criteria1. Availability of caregivers2. Age of patient and the caregiver should be >16 years3. Both should be physically fit to answer the questions.

Exclusion criteria1. Patients and their caregivers taking any medication,

which can produce cognitive and other psychological defect

2. Patients and their caregivers with other co-morbid general medical condition, those needing urgent attention for physical problems

3. Patients without caregivers who can give reliable and adequate information

4. Those who did not give consent for the study.

RESULTS

Table 1 shows the sociodemographic variables of patients and caregivers. The total number of patients are 70 (n = 70). The mean age of patients is 37.76 ± 7.84. All patients were males. With reference to education, the sample was divided into four categories: illiterate, <5 years, 6–10 years, and >10 years. Majority are employed. Depending on the family income, patients were divided into four categories: <5000 Rs./month, 5000–10,000 Rs./month, 10,000–15,000 Rs./month, and >15,000 Rs./month. Majority of the patients were in the category of <10,000 Rs./month. Majority of the patients belonged to nuclear family. Majority are from rural locality. The mean of age of caregivers among alcohol-dependent patients is 33.03 ± 9.17. All the caregivers of alcohol-dependent patients were females. Majority of the caregivers were unemployed.

Table 2 shows the comparison of sociodemographic variables with the severity of caregiver burden.

The mean age of the caregivers is 33.03 ± 9.17. Comparing the amount of burden among the three age groups, it is found that burden is more seen in age groups of



16–30 years and 31–45 years than in caregivers whose age is >45 years. Young caregivers experience more burden. This may be because of the presence of any dysfunctional and disabled family member effects their mental health and brings down their productivity. Education level of the caregivers is divided into four subgroups of illiterate, 0–5 years, 6–10 years, and >10 years. Burden, when compared among these four subgroups, it is found that there is not much difference observed in our study.

Comparison of severity of alcohol dependence in patients and burden in caregivers is depicted in Table 3. In our study, it is found that severe burden is seen in caregivers of patients having severe alcohol dependence.

DISCUSSION

Burden is more experienced by the caregivers who are unemployed than the employed group. This is an

obvious fact as unemployment precedes the poverty and impoverishment which inevitably is a cause for burden. Burden in caregivers is not much affected in relation to the duration of marital life. Severe burden is more commonly seen in those families where domestic violence is present.

Drunkenness and alcohol misuse by the male partner are associated with poor mental health and spousal violence among married women in India.[13-15] Kendler et al.[16] have noted the multifactorial nature of depression, highlighting the role of stressful life events and negative interpersonal relations. Specifically, risks associated with male partners’ alcohol use problems for women’s depression have been shown to present an additive burden to women’s mental health, exceeding those associated with women’s own alcohol use disorders or domestic violence.[17,18]

The association between these two variables is statistically significant (P < 0.05). This is an obvious and self-explanatory finding as alcohol dependence in individual effects his physical and mental health which causes a terrible plight in the caregivers. Women whose partners had alcohol problems were more likely to experience victimization, injury, mood disorders, anxiety disorders, and being in fair or poor health than women whose partners did not have alcohol problems. They also experienced more life stressors and had lower mental/psychological quality-of-life scores. Partner alcohol problems pose diverse health threats for women that go beyond their well-documented association with domestic violence.[19]

Alcohol ranks high as a cause of disease burden. Drunkenness and alcohol misuse by the male partner are associated with poor mental health and spousal violence among married women in India.[13-15] Research outside India documents that men’s alcohol problems increase the risk of depression in their female partners;[17,18,20] exceeding the risks associated with women’s own alcohol use disorders or spousal violence.[18]

Gender inequities play a key role in women’s health,[21,22] including in the impact of spousal violence[15] but have not been included in studies on partner alcohol use and women’s mental health. Alcohol misuse represents a public health crisis in India that has yet to receive adequate attention.[23,24] Similarly, most studies do not include women’s own alcohol use and may overestimate associations between partner alcohol use and depression in women.[18]

SUMMARY AND CONCLUSIONS

1. The mean age of patients is 37.76 ± 7.84. All patients were males and majority are employed. Majority of

Table 1: Sociodemographic variables among the patientsVariable Patients with ADS

(n=70), n (%)Caregivers

(n=70), n (%)

Age (years) 37.76±7.84 33.03±9.1716-30 14 (20) 21 (30)31-45 41 (58.6) 41 (58.6)>45 15 (21.4) 8 (11.4)Total 70 (100) 70 (100)

SexFemale 0 (0) 70 (100)Male 70 (100) 0 (0)Total 70 (100) 70 (100)

EducationIlliterate 28 (40) 48 (68.6)<5 years 7 (10) 7 (10)6-10 years 20 (28.6) 13 (18.6)>10 years 15 (21.4) 2 (2.8)Total 70 (100) 70 (100)

OccupationUnemployed 19 (27.1) 45 (64.3)Employed 51 (72.9) 25 (35.7)Total 70 (100) 70 (100)

Family income (Rs./month)<5000 32 (45.7) 32 (45.7)5000-10,000 27 (38.6) 27 (38.6)10,000-15,000 10 (14.3) 10 (14.2)>15,000 1 (1.4) 1 (1.4)Total 70 (100) 70 (100)

Date of marriage life (years)<10 26 (37.1) 26 (37.1)11-20 26 (37.1) 26 (37.1)21-30 11 (15.7) 11 (15.7)31-40 7 (10) 7 (10)Total 70 (100) 70 (100)

Family typeExtended 16 (22.8) 16 (22.9)Nuclear 54 (77.1) 54 (77.1)Total 70(100) 70(100)

LocalityUrban 18 (25.7) 18 (25.7)Rural 52 (74.3) 52 (74.3)Total 70 (100) 70 (100)

ADS: Alcohol dependence syndrome



them had a family income <10,000 Rs./month. Majority belonged to nuclear family and belonged to rural locality

2. The mean of age of caregivers among alcohol-dependent patients is 33.03 ± 9.17. All the caregivers of alcohol dependence patients were females. Majority of the caregivers were unemployed

3. More amount of burden is seen in age groups of 16–30 years and 31–45 years than in other age groups

4. In the caregivers of ADS, severe burden is more seen in females, unemployed, in families where domestic violence is present

5. Difference in educational level did not contribute to any difference in the burden experienced by caregivers

6. More severe is the dependence, more is the amount of burden experienced by the caregivers.

Limitations1. The time-bound nature of the study dictated a small

sample size

2. Al l the pat ients with a lcohol dependence syndrome were male and all their caregivers were females of whom most of them are spouses of the patients

3. Restricted nature of sample means that the findings are not readily applicable to other population

4. Assessment was cross-sectional and nonblind5. Those who did not/never attend outpatient department

were obviously out of study6. On direct enquiry, there could be chances of wrong

information7. Several factors such as coping, expressed emotions

were not assessed.



Table 3: Comparison of severity of alcohol dependence in patients and burden in caregiversVariable No burden (%) Moderate burden (%) Severe burden (%) Total (%) Statistical analysis

Severity of dependenceMild dependence 1 (33.3) 1 (33.3) 1 (33.3) 3 (100) χ2=11.8

df=4P=0.0186 (S)

Moderate dependence 1 (4.34) 10 (43.47) 12 (52.17) 23 (100)Severe dependence 0 (0) 17 (38.6) 27 (61.3) 44 (100)Total 2 28 40 70 (100)

S: Significant

Table 2: Comparison of sociodemographic variables with burden in caregivers of ADSVariable No burden (%) Moderate burden (%) Severe burden (%) Total (%) Statistical analysis

Age (years)16–30 0 (0) 9 (42.8) 12 (57.1) 21 (100) χ2=3.37

df=4P=0.49

31–45 1 (2.4) 16 (39.02) 24 (58.5) 41 (100)>45 1 (12.5) 3 (37.5) 4 (50) 8 (100)Total 2 (2.85) 28 (40) 40 (57.1) 70 (100)

SexMale 0 0 0 0Female 2 (2.85) 28 (40) 40 (57.1) 70 (100)Total 2 (2.85) 28 (40) 40 (57.1) 70 (100)

EducationIlliterate 1 (2.08) 24 (50) 23 (47.9) 48 (100) χ2=10.15

df=6P=0.1185

<5 years 0 (0) 0 (0) 7 (100) 7 (100)6–10 years 1 (7.69) 4 (30.7) 8 (61.53) 13 (100)>10 years 0 (0) 0 (0) 2 (100) 2 (100)Total 2 (2.85) 28 (40) 40 (57.14) 70 (100)

OccupationUnemployed 2 (4.44) 17 (37.77) 26 (59.09) 45 (100) χ2=1.27

df=2P=0.52

Employed 0 (0) 11 (44) 14 (56) 25 (100)Total 2 (2.85) 28 (40) 40 (57.14) 70 (100)

Date of marriage life (years)<10 0 (0) 10 (38.4) 16 (61.5) 26 (100) χ2=7.92

df=6P=0.24

11–20 0 (00) 13 (50) 13 (50) 26 (100)21–30 1 (9.09) 3 (27.2) 7 (63.6) 11 (100)31–40 1 (14.28) 2 (28.5) 4 (57.1) 7 (100)Total 2 (2.85) 28 (40) 40 (57.1) 70 (100)

Domestic violencePresent 0 (0) 8 (32) 17 (68) 25 (100) χ2=2.53

df=2P=0.28

Absent 2 (4.44) 20 (44.4) 23 (51.1) 45 (100)Total 2 (2.85) 28 (40) 40 (57.1) 70 (100)

ADS: Alcohol dependence syndrome



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4. Chakravarthy C. Community workers estimate of drinking and alcohol related problems in rural areas. Indian J Psychol Med 1990;13:49-56.

5. Platt S. Measuring the burden of psychiatric illness on the family: An evaluation of some rating scales. Psychol Med 1985;15:383-93.

6. World Health Organization. Burden of Mental and Behavioral Disorders, the World Health Report, Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001.

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24 © 2018 Archives of Mental Health | Published by Wolters Kluwer - Medknow

Internet addictive behaviors and subjective well‑being among 1st‑year medical students

Vedalaveni Chowdappa Suresh, Wilma Delphine Silvia1, Haradanahalli Giriprakash Kshamaa2, Swarna Buddha Nayak

Departments of Psychiatry and 1Biochemistry, Akash Institute of Medical Sciences and Research Centre, 2Department of Psychiatry, Kempegowda Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India

INTRODUCTION

Internet usage has grown significantly in the past few decades and has led to addictive behaviors.[1] Addiction potential of internet has been recognized from 1996, and

subsequently criteria have been proposed to diagnose addiction, trying to focus on its uncontrollable and harmful effects.[2,3] Harmful effects of excessive usage of internet, especially for gaming, were reported in Asian countries

Context: Exponential rise in internet usage over the past two decades has fostered internet addictive behaviors, especially in young adults. In India, medical students undergo tremendous stressful situations and are a vulnerable group for such addictive behaviors.Aims: The aim of the study was to assess subjective happiness of 1st-year medical students and their internet addiction levelsSettings and Design: A cross-sectional study done in a medical college in Bangalore, Karnataka, India.Materials and Methods: Sample consisted of 150 1st-year medical students, who self-reported about their internet addictive pattern and subjective well-being on Internet Addiction Test and Subjective Happiness Scale, respectively.Statistical Analysis: Descriptive and inferential statistical analyses were carried out. Significance is assessed at 5% level of significance. Analysis of variance, Student’s t-test, and Chi-square/Fisher’s Exact test have been used.Results: Of the total sample, 42.7% of students reported of experiencing subjective happiness below the average, 41.3% had average happiness levels, and only 16% had scores above the average. Out of the students, 42.1% who had no internet addiction, 36.4% who had mild levels, and 54.8% who had moderate levels of internet addiction fell below the average happiness level.Conclusions: Those who had higher levels of internet addiction showed reduced subjective happiness. Thus, those who experience decreased subjective happiness without overt psychological disturbances are still prone to have addictive patterns. This should be considered during screening for addictive behaviors.

Keywords: Internet addiction, medical students, subjective well-being

Abstract



DOI:10.4103/AMH.AMH_3_18

Address for correspondence: Dr. Vedalaveni Chowdappa Suresh, Department of Psychiatry, Akash Institute of Medical Sciences and Research Centre, Devanahalli, Bengaluru ‑ 562 110, Karnataka, India. E‑mail: [email protected]

How to cite this article: Suresh VC, Silvia WD, Kshamaa HG, Nayak SB. Internet addictive behaviors and subjective well-being among 1st-year medical students. Arch Ment Health 2018;19:24-9.



Original Article

Suresh, et al.: Internet addictive behaviors and subjective well-being among 1st-year medical students


such as South Korea and China, and were later found to be present across various cultures and populations.[4,5] However, it lacks a proper suitable definition, which is also due to various terminologies given to the addiction patterns such as internet addiction, internet dependency, and internet pathological use. Addictive patterns are seen in various domains such as gaming, sexual needs, and communication.[2,6] Components such as excessive use, loss of control, withdrawal features and tolerance, associated with other addictive disorders, have also been found related to addictive internet usage, prompting a plea for its inclusion in DSM-V, and this remains inconclusive.[7,8] Proposed etiologies also range from genetic factors, biological vulnerabilities, psychological issues, social interaction patterns, and cultural issues.[9]

Whether it should be included in classification systems or not, and subsequent consequences of either, will emerge with further research. However, there is no denying that, while on one hand internet has become an essential and indispensable commodity useful in most of our daily lives, excessive use with addiction potential and psychological disturbances associated with it have also become common.[9] While South Korean studies point to increase cardiovascular risk in addicted individuals, psychiatric comorbidities such as anxiety, depression, attention deficit hyperactive disorder, alcohol dependence, and abuse are associated with internet addiction. In addition, negative coping skills, cognitive distortions, decreased self-esteem, reduction in social interactions in real life (as opposed to virtual social communication), and an overall poor psychological status are frequent in those who have addictive usage patterns.[5,9] Internet provides easy opportunities for leisure, virtual communication, gaming, sexual satisfaction, and even shopping giving multiple and unpredictable rewards and thus reinforcing the addictive behavior. Thus, a vicious cycle is formed from which students fail to get out.[9]

Most studies done in India regarding internet usage pattern have shown milder levels of addictive behaviors and increased psychological distress, anxiety, and depressive features.[10-12] The at-risk population is young adults, mainly belonging to age range of 18–34 years.[13,14] This age group, in India, encompasses students who are pursuing medical course. They face various stressful conditions owing to the lengthy duration of the course, which often spans over a decade, its vast and difficult academic scope, financial difficulties regarding fee structures, high expectations from family and relatives, adjusting to a new environment away from the family, and difficulties in interpersonal relationships.[15,16] These in turn decrease learning abilities

and cause emotional and psychological distress.[17,18] To deal with various problems, students often use faulty strategies and negative coping styles, which may lead to harmful results such as addictive behaviors. Internet addiction is one such behavior which is on the rise, especially among college students. Easy accessibility at affordable prices makes internet a potential area for addictive behavior, apart from its use as modes of communication, entertainment, and academic purposes. In medical students, psychological well-being is often compromised, which may push them toward an addictive pattern of internet use, further leading to emotional stress, decreased social interactions, poor academic performance, and a poorer mental health status overall. Internet addiction is found to be higher in those who have significant anxiety and depression; however, addictive behaviors can also be found in those who have subsyndromal levels of psychological distress.[19-21] Reduction in subjective happiness gradually paves a path to higher internet usage in search for happiness, in the form of entertainment, leisure, gaming, shopping, and virtual communication, culminating into an addictive pattern.[22] Hence, the aim of this study was to assess subjective happiness of 1st-year medical students and their internet addiction levels.

Settings and designThe study sample consisted of 150 1st-year medical students of Akash Institute of Medical Sciences and Research Centre, Bangalore. Institutional Ethical Committee clearance was obtained beforehand. Students were briefly informed about the questionnaires and doubts, if any, were timely addressed. A written informed consent was taken from the students who were willing to participate in the study. Anonymity about individual identities and information provided was ensured. Students then self-reported according to Young’s Internet Addiction Test (IAT) questionnaire and Subjective Happiness Scale (SHS), which took approximately 15–20 min.

MATERIALS AND METHODS

Young’s Internet Addiction testThis instrument was developed by Dr. Kimberly Young.[2,23] It is a reliable measure of severity of self-reported compulsive internet usage. It consists of twenty items and each question is rated on a 5-point Likert scale from 0 to 5 (0 = Does not apply, 1 = Rarely, 2 = Occasionally, 3 = Frequently, 4 = Often, and 5 = Always). Total scores are calculated after adding the score on all twenty items, so as to get the score which ranges from 20 to 100. Based on the scoring, results are interpreted as follows: 0–19 points = normal range, 20–49 points = mild, 50–79 points = moderate, and



80–100 points = severe internet addictive behaviors. Higher the total scores, greater the level of internet addiction. The validity and reliability of the Young’s IAT has been evaluated in various studies.[24,25]

Subjective Happiness ScaleThis self-rated questionnaire was developed by Lyubomirsky and Lepper.[26] It has four items and each is rated on a 7-point Likert scale as follows; item number 1 (1 = not a very happy person, to 7 = a very happy person), item number 2 (1 = less happy, to 7 = more happy), item numbers 3 and 4 (1 = not at all, to 7 = a great deal), and item number 4 is reverse coded using a descending sequence. All the scores are then added up and the total divided by 4, which gives the subjective happiness score. SHS has been validated and has shown high internal consistency across various sample populations.[27] As the author of the SHS had suggested, although the average is from 4.5 to 5.5, college students tend to score lower on the scale (averaging bit below 5), than adults and older people, who are either working or have retired (averaging 5.6). Those who have a score below or equal to 4.4 are considered to experience lower levels of subjective happiness than the average, and those who score ≥5.6 are considered to experience higher levels of subjective happiness than the average.[26]

Statistical analysisThe statistical software namely Statistical Package for the Social Sciences (SPSS) version 18.0 and R environment ver. 3.2.2 (SPSS inc, Chicago, United States of America) were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables, etc. Descriptive and inferential statistical analyses have been carried out in the present study. Results on continuous measurements are presented on mean ± standard deviation (min-max) and results on categorical measurements are presented in number (%). Significance is assessed at 5% level of significance. The following assumptions on data are made: (1) dependent variables should be normally distributed and (2) samples drawn from the population should be random, and cases of the samples should be independent. Analysis of variance has been used to find the significance of study parameters between three or more groups of students; Student’s t-test (two-tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups (intergroup analysis) on metric parameters. Chi-square/Fisher’s Exact test has been used to find the significance of study parameters on categorical scale between two or more groups, nonparametric setting for qualitative data analysis. Fisher’s exact test used when cell samples are very small.

RESULTS

All the 150 1st-year medical students took part in this study. Of the total sample, 42.7% of students reported of experiencing subjective happiness below the average, 41.3% had average happiness levels, and only 16% had scores above the average. Table 1 shows the gender distribution as compared to SHS. In this study, 47.5% of males and 39.6% of females were below the average happiness score, whereas only 16.9% of males and 15.4% of females were above the average. Of the study group, 35.6% of males and 45.1% of females were in the average range of happiness. However, there was no significant difference (P = 0.508) between gender and subjective happiness.

Figure 1 shows IAT levels and its comparison with SHS. Almost 12.6% (n = 19) of students had no internet addiction, 58.2% (n = 88) students had mild level of internet addiction, and 28% (n = 28) had moderate level. Only one student reported of severe levels of addiction.

In this study, 42.1% of students who had no internet addiction and 36.4% of students who had mild levels of internet addiction had reported of being less happy subjectively, whereas 54.8% of students who had moderate level of internet addiction fell below the average happiness level. Only one student had severe level of addiction and also had a lower level of subjective happiness. In case of those students who reported of experiencing subjective happiness above the average, 21.1% had no internet

Table 1: Subjective happiness scale distribution according to gender of studentsSHS Gender Total (%)

Male (%) Female (%)

≤4.4 28 (47.5) 36 (39.6) 64 (42.7)4.5-5.5 21 (35.6) 41 (45.1) 62 (41.3)≥5.6 10 (16.9) 14 (15.4) 24 (16)Total 59 (100) 91 (100) 150 (100)

P=0.508, not significant, Chi-square test. SHS: Subjective Happiness Scale

Figure 1: Comparison of Internet Addiction Test with Subjective Happiness Scale in students



addiction, 17% and 11.9% had mild and moderate levels of addiction, respectively. Those who had an average level of subjective happiness, the majority had no addiction (36.8%) and mild addiction (46.6%), and only 33.3% had a moderate addiction. Higher levels of internet addiction showed lower levels of subjective happiness.

DISCUSSION

In this study, overall subjective happiness scores among 1st-year medical students showed that only 16% reported above-average happiness. This is consistent with the observed pattern that young adults who are students show lower levels of happiness as a group.[26] Overall, 42.7% reported of lower than average range happiness, which is a matter of concern. Although statistically not significant, females tend to report higher levels of subjective happiness than males. A qualitative assessment will give us more insights about this difference between gender.

Most of the students were found to have milder levels of internet addiction. As the level of internet addiction increased, i.e., from mild to moderate, subjective happiness decreased. Out of the students who had moderate addiction levels, 54.8% had lower happiness levels compared to 36.4% of students who had mild addiction levels. One student who had severe addiction also had low levels of happiness. Levels of addictions also negatively affected those students who reported to have more happiness than average. As the level of addiction increased from no addiction to mild and moderate levels, subjective happiness also decreased, values being 21.1% for no addiction group, 17% for mild, and 11.9% for moderate levels of addiction. Although not statistically significant (P = 0.410), we observe a general trend of lower levels of subjective happiness in association with higher levels of internet addiction.

Thus, the areas of concern to be focused are:1. Overall lower levels of subjective happiness among

medical students2. Increasing levels of internet usage with some addictive

patterns3. Lower levels of subjective happiness in those who have

higher levels of internet addiction.

Student life is a period of learning, developing a stable personality, and encouraging better ways of communication and social skills. Medical course in India comprises about 5–6 years of undergraduate course including internship and rural services, and further 3–6 years of postgraduate education, excluding years of preparation time for entrance examinations taken by the students at various points. Fee

structures vary and often pose financial problems. Parents, guardians, and relatives of students have high expectations about their academic performances and future careers, adding to stress for the students. Further, many students face a completely new environment, staying away from home and with new peers and teachers.[28,29] Prevalence of stress among medical students in India is reported to have a range of 20%–29%.[30]

Students use various coping mechanisms to deal with the stress they face. Appraisal-focused coping strategies are used by most of them, along with problem-solving and emotion-focused coping mechanisms. Females tend to use emotion-focused coping strategies more often. Appraisal-focused strategies may lead to efforts to minimize the problem areas by overlooking them, leading to avoidant behaviors.[31]

While addictive internet usage is associated with psychological distress and psychiatric comorbidities, those who have better coping mechanisms may not fall under the “disturbed” category when assessed. A student may not be perceiving stress as a psychological disturbance, but as a reduction in happiness, which is evident from this study. Happiness is seldom subjectively measured qualitatively and even less quantitatively. Thus, a student may feel happy but still has addictive internet usage patterns. This subsequently may increase the vulnerability of the individual, more so if he or she has faulty coping mechanisms. From this study, subjective happiness shows decline wherever there is increasing in addictive levels.

There is a deficit in the treatment of internet addictions, due to incomplete understanding of the phenomenology and associated behaviors, lack of diagnostic criteria, and treatment algorithms and guidelines. Controversies regarding diagnostic criteria and inclusion in classification systems will remain for time being, but treatment cannot be deferred.[32,33] Strategies for psychological perspective are suggested through cognitive-behavioral therapy techniques such as setting goals, abstinence to certain behaviors, cutting reinforcements, and strengthening of support systems. Motivational interviewing to build motivation from within oneself, with learning of new behavioral skills and coping techniques, including support groups, community and family, reality therapy, and acceptance and commitment therapy helping the clients to take responsibility of their actions and time management have all been suggested and found to be helpful, but larger studies are lacking. Pharmacotherapy has shown positive results in small studies, particularly selective serotonin reuptake inhibitors such as escitalopram alone or in combination



with quetiapine, bupropion, naltrexone, methylphenidate, and mood stabilizers. They address specific domains such as impulse control, hyperactivity and attention deficits, reward, and craving behaviors. Physical exercise, mindfulness, and relaxation techniques can also be used as adjunctive to treatment. Overall, a multimodal treatment approach with biopsychosocial model is preferred.[9]

Medical students should be considered as a vulnerable group.[34] Healthy internet usage behaviors, social skills training, strengthening positive coping styles, identifying pathological behaviors, and modes of seeking help should be included in their training. Moreover, screening of students to identify addictive behaviors should not only be restricted for those who report psychological distress. As seen in this study, they may have decreased in subjective happiness without overt psychological disturbances but are still prone to have addictive patterns. This should be considered during screening and while providing health education.

CONCLUSIONS

Internet usage has become an important tool for academics, communication, entertainment, and various other activities among medical students. However, along with its benefits, addictive usage patterns have emerged in them. This likely to rise among students, especially those who are pursuing 1st-year medical education. In this study, we have focused on how addictive patterns can decrease their happiness or how decreased happiness may foster addictive patterns. This will help us to understand the interplay between addiction and psychological status, as this study shows that addictive patterns can emerge even in students who although not psychologically distressed but experience decrease in happiness. Thus, irrespective of their psychological status, all medical students who join the medical course should be informed about healthy internet usage patterns and should also be sensitized regarding addictive patterns. This will also guide in the development of appropriate screening methods and subsequent interventions. Thus, it becomes a primary preventive step, to nip internet addiction in the bud.

Strength of the studyThis is one of the few studies, which have focused on subjective well-being of students and addictive patterns of internet usage. Decrease in subjective happiness can foster addictive pattern. Thus, this study gives a way for further research focusing on psychological/subjective well-being and addictive behaviors. Training programs should encompass all the students and should not be

restricted to only those who report or shows features of psychological distress.

Limitations of the studySmall sample group, cross-sectional design, bias that may have occurred during self-report of behaviors and various confounding factors such as presence of other addictive behaviors are possible limitations. A prospective study following up medical students, their internet usage patterns, measuring their happiness, and distresses over the course of their education will show a better pattern of internet addiction longitudinally. A qualitative design looking into happiness and coping skills would enhance our understanding of why students report lower levels of happiness overall.

AcknowledgementThe authors gratefully acknowledge Dr. Satish Babu HV, Director, AIMS & RC and Dr. Vasudeva DS, Principal, AIMS & RC, for the encouragement and constant support to carry out this project. We would like to thank all the First year medical students of batch 2017-18, Akash Institute of Medical Sciences and Research Centre, Devanahalli, Bangalore Rural, for having participated in this study. We also thank Dr KP Suresh, Principal Scientist, NIVEDI, Bangalore for statistical analysis.



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16. Chaudhari B, Menon P, Saldanha D, Tewari A, Bhattacharya L. Internet addiction and its determinants among medical students. Ind Psychiatry J 2015;24:158-62.

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18. Goel D, Subramanyam A, Kamath R. A study on the prevalence of internet addiction and its association with psychopathology in Indian adolescents. Indian J Psychiatry 2013;55:140-3.

19. Nalwa K, Anand AP. Internet addiction in students: A cause of concern. Cyberpsychol Behav 2003;6:653-6.

20. Gade S, Chari S, Gupta M. Perceived stress among medical students: To identify its sources and coping strategies. Arch Med Health Sci 2014;2:80.

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Reasons for pursuing psychiatry as a career: A qualitative study of future psychiatrists from India

Priya Sreedaran, Divya HegdeDepartment of Psychiatry, St. John’s Medical College Hospital, Bengaluru, Karnataka, India

INTRODUCTION

India is currently facing a huge deficit of psychiatrists as well as other mental health-care workers.[1,2] The National Mental Health Program has attempted to address this by focusing on capacity building and has recommended increasing the number of postgraduate psychiatry seats.[3] However, this measure might not yield results, if we are

unable to recruit adequate number of medical graduates to psychiatry. While research has indicated that medical graduates have negative attitudes toward psychiatry, there is very little information on the actual reasons that compel Indian medical graduates to finally select psychiatry as a career.[4-6]

Context: Despite extensive research on the attitudes of medical students toward psychiatry in India as well as worldwide, the actual reasons due to which medical graduates finally select psychiatry for their future careers is still unclear.Aims: To explore the lived experiences of postgraduate psychiatry students pertaining to their reasons for choosing psychiatry for future specialization.Settings: In an Indian medical college general hospital psychiatry setting.Methods and Materials: A qualitative study using focus group discussions and in-depth interviews with postgraduate psychiatry students.Statistical Analysis: Content analysis was used to identify direct and latent themes and develop a model.Results: Major themes underlying the reasons for choosing psychiatry are categorised into candidate related factors, medical college related factors, those related to process of Indian postgraduate medical selection, factors relating to psychiatry as a subject and social factors.Conclusion: The interaction between potentially interested medical under-graduates, their experiences of psychiatry during medical college along with the current system of postgraduate medical selection plays a major role in medical graduates pursuing psychiatry.Key Message: In order to improve future psychiatry recruitment rates in India, the quality of undergraduate psychiatry teaching should be improved. Professional psychiatry organizations should systematically engage with interested medical under-graduates and try to participate in the postgraduate selection process.

Keywords: Career, medical education, medical graduates, postgraduate, psychiatry, recruitment

Abstract



DOI:10.4103/AMH.AMH_2_18

Address for correspondence: Dr. Priya Sreedaran, St. John’s Medical College Hospital, Bengaluru ‑ 560 034, Karnataka, India. E‑mail: [email protected]

How to cite this article: Sreedaran P, Hegde D. Reasons for pursuing psychiatry as a career: A qualitative study of future psychiatrists from India. Arch Ment Health 2018;19:30-6.



Original Article

Sreedaran and Hegde: Reasons for psychiatry as a career


It is in this background that we decided to explore the reasons for pursuing psychiatry as a career among Indian psychiatry postgraduate students.

MATERIALS AND METHODS

AimThe aim of the study was to explore the experiences of postgraduate psychiatry students with respect to their reasons for choosing psychiatry as a career.

We adopted a qualitative design as this permitted us to delve into the various aspects in great detail. We followed the Consolidated Criteria for Reporting Qualitative research 32 checklist and other standard recommendations in designing the study as well as reporting on the findings.[7,8]

SettingsThe study was conducted in a private South Indian medical college with a general hospital psychiatry unit and a postgraduate psychiatry program of more than 10-year duration. All interviews with subjects except for two were performed at the study site by the first author with no other person present other than the interviewer and the subject. Two interviews were conducted through teleconferencing with no other individuals present in the interviewer’s room at that time.

Author informationBoth the authors have a combined postgraduate psychiatry teaching experience of more than 10 years. The study was designed by the first author who also carried out all the subject interviews. The first author and the second author jointly did all aspects of the analysis and reporting. The first author was acquainted with all the subjects to some extent before conducting the interviews.

Sampling, inclusion and exclusion criteriaWe performed this study on a purposive sample of motivated postgraduate psychiatry students. We deliberately selected subjects who had completed at least a year of psychiatry residency as we assumed that they would have obtained adequate time to reflect upon their choice and would have adapted to their work. We excluded those who had significant absenteeism in their work as this could potentially be a proxy for disinterest in the subject.

Ethical considerationsWe were aware that all potential participants in this study were also simultaneously being supervised by the authors of this study and thus could find it difficult to refuse consent to the study. The study authors had no administrative or disciplinary power over the subjects at the time of conduct

of study, and this was clearly stipulated to the subjects at the time of interview. We included transcripts of only those who gave subject informed consent at the time of interview as well as after scrutiny of their transcripts. The study was approved by the Institutional Ethics committee in the year July 2014 (105/2014).

SubjectsThe subject interviews were in the form of in-depth interviews and focus group discussions. On two separate occasions, the subjects were also interviewed in a group of two (dyadic interview) and three (triadic interview). While most qualitative studies use focus groups and single subject in-depth interviews, research indicates that interviewing subjects in pairs or triads is a valid strategy.[9] Whenever more than one subject was being interviewed, the grouping was kept as homogenous as possible so that the subjects would be able to verbalize their experiences freely. The process of conducting the study along with various stages of analysis has been depicted in Figure 1.

Interview guideWe used a semi-structured interview guide designed on the basis of prior literature review and our findings from a pilot interview. The probes underlying the interview guide were as follows:• What are the reasons for choosing psychiatry?• At what time period of their life did they consider

selecting psychiatry?• What were the then underlying influences?• What was the role of their undergraduate medical

education on the choice of psychiatry?• What were the other factors that contributed to

selection of psychiatry?

Altogether we conducted one focus group discussion (n = 6), one dyadic interview (n = 2), one triadic interview (n = 3), and seven single subject interviews. The mean duration of all interviews was approximately 30 min. We directly approached 21 subjects at the study site after observing

Figure 1: Process of the conduct of the study



their work. Three candidates were not interviewed on account of logistic reasons. We obtained 18 interviews. We did not obtain consent from one subject to use the transcript. As we achieved theoretical saturation after the analysis of transcripts of 17 subjects, we stopped recruiting subjects subsequently.

AnalysisThe data were analyzed using the framework of content analysis jointly by the authors who performed a manifest as well as latent content analysis.[10] In the manifest content analysis, the directly expressed words or phrases in the text of the transcript were used to identify important units of meaning and coded in vivo. In the latent content analysis, the aim was to also find out the underlying meaning of the text. We also attempted to generate an overall impression from the text. We used the QSR NVivo 7 qualitative software to perform the manifest content analysis.

We performed the analysis intending to reduce the number of categories and subcategories into broader categories by constant comparison and refinement. We performed participant checking and mailed these findings to the participants with certain other queries to resolve doubts about categories. We incorporated the clarifications from the subjects in the analysis and thus triangulated our data.

We established a set of main categories by grouping together all the subcategories with similar meanings. These were reviewed to identify the emerging themes and categories and were compared to those from previously published literature. Illustrative quotations for most of the subcategories were chosen from the transcripts for the themes according to standard practices in qualitative research.[7,8] Confidentiality was ensured by removing all identifiers of participants. Each participant instead received an alphanumeric prefix.

Figure 2: Participant details according to the institution

RESULTS

For participant-related details, refer to Figure 2 and Table 1.

The ages of all the candidates in the study were within the range of 25–35 years. Of the 17 interviewed subjects, one participant considered psychiatry as a future vocation during school, 12 considered psychiatry during medical college and internship, and remaining 4 considered psychiatry while studying for their postgraduate medical entrance examination. While 14 reported that their undergraduate medical education served as a significant influence on their selection of psychiatry as a career, medical college did not play a significant role for remaining three candidates. Ten of the subjects were from a South Indian private medical college with general hospital psychiatry unit, six were from a tertiary central government mental health institution, and one was from a central government training institute with general hospital psychiatry unit.

On analysis of transcripts, the categories were candidate-related, medical college and undergraduate training related, related to process of postgraduate selection, social factors related, and factors related to psychiatry as a subject. Figure 3 and Table 2 display all major themes and minor themes with some associated illustrative statements.

Major theme 1: Candidate‑related reasonsThese were factors that appeared independent of the quality of medical education received by the participants.

Figure 3: Major and minor themes in reasons for psychiatry as a career

Table 1: Participant distribution according to year of residency and genderGender Male (n=10) Female (n=7)

Year of residency: Second year 9 3Year of residency: Third year 0 2Within year of completing residency 1 2



Some of these factors were inherent in the candidates even before their entry into medicine. Certain other factors appeared to play a greater role toward the end of medical college as the candidates actively began planning for their future.

Major theme 2: Subject‑related reasonsThis refers to reasons associated with psychiatry as a subject which made it attractive to candidates for their future career. These ranged from the focus on observing and understanding human behavior to the perception of candidates that lifestyle of psychiatrists was less stressful.

Major theme 3: Reasons related to medical college training and educationThis appears to be determined primarily by the type of medical education that candidates received. For some candidates, psychiatrists served as inspirational role models.

Major theme 4: Reasons related to process of postgraduate selection in our countryThis theme refers to the factors arising from the system of postgraduate selection in India which appears to play an important role in candidates opting for psychiatry. These include a candidate’s rank in the examination and

candidates’ preference for particular national institutes as opposed to a specific medical specialization.

Major theme 5: SocialThis referred to the social factors that appeared to serve as motivators for candidates to choose psychiatry. While some candidates selected psychiatry in order to improve stigma associated with mental illnesses, certain other candidates selected psychiatry under the influence of books.

We have further reflected on these themes and have attempted to represent the relationship between these categories using a model [Figure 4].

From this model, we hypothesize that candidate-related factors at several stages of the candidate’s life along with social factors create an initial tendency toward psychiatry. This interaction under the influence of the quality of exposure to psychiatry received at medical college at undergraduate level further strengthens the inclination toward psychiatry in certain candidates. Some of these candidates due to the postgraduate selection process eventually select psychiatry as a career.

Table 2: Major and Minor themes underlying reasons for selecting psychiatry and illustrative quotesCategories Subcategories Illustrative quotes

Candidate related Ambition P1:”I had already seen myself as a person who was altering the mental health of the country”

Personal experience with mental illness

P4: “I had some encounters among close ones who have had some psychiatric illnesses. I have seen them go through a bad period of time”

Aptitude P2: “Somewhere I was oriented to Neuropsychiatry. I picked it up faster than other entrance exam subjects”

Interested in Research P12: “I did research in psychiatry in my UG days. I thought that I could take this up well”

Subject related Neurology and Mind related P3: “The body is now divided into so many pieces and so many people trying to figure out all that but there are very few people trying to understand the mind. So that was the one thing which drove me towards psychiatry”

Human behavior P4: “I kind of understood that all this behavior, this had a neurological basis and that kind of rather than just saying it is just behavior, it is this or that there was something to explain it and I felt that this is the field to pursue”

Lifestyle related P5: “It is not hectic like surgery where they will call in the middle of the night”Medical college and undergraduate training related

Clinical exposure P7: “I worked in the psychiatry department in my internship and I felt that was the most interesting part of my internship. I actually thought that I could continue working like this for the rest of my life”

Psychiatrist as role model P8: “I had my inspiration from psychiatry HOD”Process of postgraduation selection in India related

Qualifying through Entrance exam

P9: “It so happened that Psychiatry entrance was the first one that clicked”

Preference for central institute

P7: “I just thought that doing psychiatry at a national institute would be better than doing medicine at state government hospital”

Social factors related Stigma P10: “There are so many close ones suffering from schizophrenia. Because I have seen them. There is still stigma in the part where I am living. And I thought after MBBS, I can still help them in that part of thing”

Peer influence P11: “I had considered it as an option but not the first option. But later on, when I spoke to my seniors and some of my family friends who had been in psychiatry, had taken up Psychiatry already I realized I can do it. So then I chose psychiatry because of that”

Popular influence (books, movies)

P4: “I came across a lot of novels with description of psychiatric illness. I was interested; I wanted to know more about these things”



DISCUSSION

Published literature reveals that, worldwide, recruitment rates of psychiatrists are quite low. In the United Kingdom, the recruitment rates into psychiatry are around 4%–5% with similar depressing figures from other countries.[11-14] Several authors have tried to understand this by conducting studies on medical graduates using postal surveys, questionnaires, and interview schedules.[4-6,11,15,16] We decided to study postgraduate psychiatry residents as these were individuals who had made a commitment to pursue a future career in psychiatry and were likely to remember the reasons for doing so. Due to the lack of data available from India in this aspect, we used a qualitative design to achieve a deeper understanding of the underlying causes that made certain Indian medical graduates pick a relatively unpopular specialty like psychiatry. Our study demonstrates that there were five major categories that could possibly explain these reasons. While some of these are similar to previously published findings from other countries, certain other factors such as those relating to process of postgraduate medical selection appear unique to our sample.

A theme that came up in our study was that some candidates were inclined toward psychiatry due to their personal experience of a significant loved one being affected with mental illness. This is similar to findings from a large twenty-country study of medical graduates that included subjects from India.[15] Other studies have reported that medical students hailing from liberal arts background were associated with a possible inclination toward psychiatry.[16,17] We did not come across this in our study. The perceived liberal bias in most potential psychiatrists from the West might not apply to India as most students enter medicine directly after their high school examinations and often have no exposure to the field of humanities after their 10th standard.

In another Indian study that looked at attitudes of medical students toward psychiatry, female medical students were more likely to consider a future vocation in psychiatry.[18] We speculate that women medical graduates, in general, might feel more compelled to take up subjects like psychiatry that are perceived as less stressful for specialization as they might also have to consider the traditional duties expected of Indian women in addition to the demands of a doctor’s career. This could be a reason that our study did not uncover a gender-related theme.

Our study demonstrated that psychiatry as a subject was attractive to certain candidates who were interested in studying neurological basis of behavior. These findings are similar to a study done in United Kingdom on consultant psychiatrists where the similarities between psychiatry and neurosciences were among the important reasons for choosing psychiatry as a vocation.[19] Psychiatry was also selected for a future career in view of perceived less stressful lifestyle reflecting upon the increasing current emphasis on maintaining a positive work-life balance.[20]

Our study shows that positive medical college exposure to psychiatry at an undergraduate level including charismatic psychiatry teachers does have the potential to increase the likelihood for medical students to select psychiatry. This is important as many medical students harbor primarily negative attitudes toward psychiatry.[4,21] Medical students even without any prior clinical exposure have been shown to begin their medical education viewing a career in psychiatry as distinctly less attractive than other medical specialties![12] A high proportion of medical students from India experienced negative emotions while interacting with mentally ill patients.[5] Medical students, in addition to possessing poor knowledge in the subject, were often unable to conceptualize psychiatric conditions within a biopsychosocial framework and some even believed that supernatural and paranormal reasons caused mental disorders.[5,22] All of these are indications that, irrespective of whether medical graduates choose to further specialize in psychiatry or not, a lot of effort still needs to be put to remove the various misconceptions against psychiatry as a subject. As several authors have suggested, a greater prominence given to psychiatry in undergraduate curriculum might remedy some of these knowledge gaps.[23]

Social factors such as alleviating stigma associated with mental illness seem to be important reasons for some individuals to choose psychiatry. These bear resemblance to a study in Canada which demonstrated that those students who were more interested in psychiatry had a greater social and lesser hospital orientation as compared to

Figure 4: Hypothetical model showing the interaction between various themes



those students interested in other specialties.[17] Popular influences such as books and movies continue to play a role in increasing interest in psychiatry. It is hence necessary that psychiatrists remain sensitive to their popular portrayals and continue to engage with the media innovatively.

Finally, in India, the entire process of postgraduate medical selection brings its own set of variables which have a definite influence on the recruitment rates into psychiatry.[24] With the uncertainty over status of a common entrance examination for medical postgraduation, there is an uneven system of postgraduate admission in India.[24] Our study reveals that some candidates have selected psychiatry on the basis of the institution that they got into and on the basis of their qualifying examination rank. Farooq et al. recommend that countries with low recruitment rates should identify underlying specific national factors.[15] We suggest that various Indian psychiatric associations should take an active role in the entire system of postgraduate medical selection as this is an important variable influencing recruitment into psychiatry.

Another variable relating to process of postgraduate medical selection is the preference of some candidates for central institutes. The government of India’s decision to open several central medical institutes might improve future recruitment rates in psychiatry.

LimitationsWe used a qualitative design, and hence our study might suffer from the perceived limitations associated with qualitative research techniques such as small sample size and authors’ bias. It is to be noted that, in qualitative studies, theoretical saturation determines the sample size and can be achieved with sample size much lower than that for quantitative studies. The settings from where the subjects were recruited could also have influenced the results. Those subjects from other private colleges or state government psychiatry training institutes might have a different perspective on their reasons for selecting psychiatry. It is also important to keep in mind that there was a prior relationship between authors and subjects, and it is possible that certain subjects might not have fully disclosed their experiences.

CONCLUSION

Our study reveals that, in addition to continuing to develop innovative ways to train medical undergraduates in psychiatry, it is important to identify and engage with future psychiatrists at undergraduate level itself. Simultaneously, we should keep in the mind that the current medical postgraduate selection process plays a key role

in recruitment to psychiatry and this could influence the future psychiatry recruitment rates as well as the consequent capacity building of mental health services in India.



REFERENCES

1. Thirunavukarasu M, Thirunavukarasu P. Training and national deficit of psychiatrists in India – A critical analysis. Indian J Psychiatry 2010;52:S83-8.

2. Patel V. The future of psychiatry in low- and middle-income countries. Psychol Med 2009;39:1759-62.

3. Sinha SK, Kaur J. National mental health programme: Manpower development scheme of eleventh five-year plan. Indian J Psychiatry 2011;53:261-5.

4. Praharaj SK, Behere RV, Deora S, Sharma PS. Psychiatric specialization as an option for medical students in the Indian context. Int Rev Psychiatry 2013;25:419-24.

5. Kato TA, Balhara YP, Chawla JM, Tateno M, Kanba S. Undergraduate medical students’ attitudes towards psychiatry: An international cross-sectional survey between India and Japan. Int Rev Psychiatry 2013;25:378-84.

6. Gulati P, Das S, Chavan BS. Impact of psychiatry training on attitude of medical students toward mental illness and psychiatry. Indian J Psychiatry 2014;56:271-7.

7. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349-57.

8. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: A synthesis of recommendations. Acad Med 2014;89:1245-51.

9. Morgan DL, Ataie J, Carder P, Hoffman K. Introducing dyadic interviews as a method for collecting qualitative data. Qual Health Res 2013;23:1276-84.

10. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105-12.

11. Goldacre MJ, Fazel S, Smith F, Lambert T. Choice and rejection of psychiatry as a career: Surveys of UK medical graduates from 1974 to 2009. Br J Psychiatry 2013;202:228-34.

12. Feifel D, Moutier CY, Swerdlow NR. Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry 1999;156:1397-402.

13. Wiesenfeld L, Abbey S, Takahashi SG, Abrahams C. Choosing psychiatry as a career: Motivators and deterrents at a critical decision-making juncture. Can J Psychiatry 2014;59:450-4.

14. Nortje G, Seedat S. Recruiting medical students into psychiatry in lower income countries. Int Rev Psychiatry 2013;25:385-98.

15. Farooq K, Lydall GJ, Malik A, Ndetei DM; ISOSCCIP Group, Bhugra D. Why medical students choose psychiatry – A 20 country cross-sectional survey. BMC Med Educ 2014;14:12.

16. Gowans MC, Glazier L, Wright BJ, Brenneis FR, Scott IM. Choosing a career in psychiatry: Factors associated with a career interest in psychiatry among Canadian students on entry to medical school. Can J Psychiatry 2009;54:557-64.

17. Farooq K, Lydall GJ, Bhugra D. What attracts medical students towards psychiatry? A review of factors before and during medical school. Int Rev Psychiatry 2013;25:371-7.



18. Prathaptharyan TJ, Annatharyan D. Attitudes of tomorrow’s doctors’ towards psychiatry and mental illness. Natl Med J India 2001;14:355-9.

19. Dein K, Livingston G, Bench C. Why did I become a psychiatrist? Survey of consultant psychiatrists. Psychiatrist 2007;31:227-30.

20. Rao TS, Indla V. Work, family or personal life: Why not all three? Indian J Psychiatry 2010;52:295.

21. Lyons Z. Attitudes of medical students toward psychiatry and psychiatry as a career: A systematic review. Acad Psychiatry 2013;37:150-7.

22. Chawla JM, Balhara YP, Sagar RS. Undergraduate medical students’ attitude toward psychiatry: A cross-sectional study. Indian J Psychiatry 2012;54:37-40.

23. Rao TS, Rao KN, Rudrappa DA, Reddy DR. Medical students’ attitudes to psychiatry: Interest to specialize in psychiatry. Indian J Psychol Med 1989;12:23-8.

24. Solanki A, Kashyap S. Medical education in India: Current challenges and the way forward. Med Teach 2014;36:1027-31.


Disability in bipolar affective disorder patients in relation to the duration of illness and current affective state

R. S. Swaroopachary, Lokesh Kumar Kalasapati1, Sarath Chandra Ivaturi, C. M. Pavan Kumar Reddy2

Department of Psychiatry, SVS Medical College, Mahabubnagar, 1Department of Psychiatry, Bhaskar Medical College, 2Department of Psychiatry, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India

INTRODUCTION

Bipolar affective disorder (BPAD) is an episodic illness in which episodes of depression/Mania/Mixed/Hypomania occur. BPADs are dimensional illnesses in which patients’ experience, during long‑term

course of illness, fluctuating levels of severity of manic and depressive symptom interspersed with symptom‑free (euthymic) periods.[1] The current prevalence of (BPAD) is 0.4%–0.5%, 1‑year prevalence is 0.5%–1.4% and lifetime prevalence is 2.6%–7.8%.[2] In India, the prevalence of affective disorder ranges from

Background: Bipolar affective disorder (BPAD) is an episodic illness in which episodes of depression/Mania/Mixed/Hypomania occur. BPAD has been found to be associated with the following types of disability: increased suicidal behavior, higher unemployment, higher dependence on public assistance, lower annual income, and increased work absenteeism owing to illness, decreased work productivity, poorer overall functioning, lower quality of life, and decreased lifespan. The two affective disorders, major depressive disorder, and bipolar disorders were associated with the large decrements in functioning. Bipolar disorder was particularly strongly associated with having missed time at work. Depressive disorders have been associated with a larger number of disability days and poorer role functioning than several common general medical diseases – arthritis, hypertension, and diabetes.Aims: This study aims to study the disability in bipolar patients in relation to the duration of their illness and current effective state.Methodology: Clinical and sociodemographic details of patients and caregivers were collected using a semi‑structured pro forma. Indian Disability Evaluation and Assessment Scale is used to assess patients’ disability. The diagnosis of BPAD is made in accordance with the International Classification of Disease‑10 criteria.Results: Severe disability is seen where the duration of illness is <10 years. Among depressive patients, the disability is found to of moderate level whereas patients who have a current manic episode experienced severe disability.Conclusions: Severe disability is seen where the duration of illness is <10 years.

Keywords: Bipolar affective disorder, current effective state, duration of illness

Abstract



DOI:10.4103/AMH.AMH_5_18

Address for correspondence: Dr. R. S. Swaroopachary, Department of Psychiatry, SVS Medical College, Mahabubnagar ‑ 509 001, Telangana, India. E‑mail: [email protected]

How to cite this article: Swaroopachary RS, Kalasapati LK, Ivaturi SC, Reddy CM. Disability in bipolar affective disorder patients in relation to the duration of illness and current affective state. Arch Ment Health 2018;19:37-41.



Original Article

Swaroopachary, et al.: Disability in bipolar affective disorder

38 Archives of Mental Health | Volume 19 | Issue 1 | January‑June 2018

0.51 per thousand population[3] to 20.78 per thousand population.[4]

Physical functioning refers to the ability of an individual to carry out daily activities such as dressing and bathing, the capacity to perform physical tasks such as exercise, and the extent of any restriction in physical activity such as partial or complete days of rest in bed (bed days).[5,6] Measures of physical functioning, such as disability days, are commonly used as indicators of the need for services in health policy services and planning or allocating services. These measures are assumed to reflect physical rather than psychiatric problems.[7,8] Long‑term outcome studies have found that nearly one‑third of manic patients have poor work performance and adjustment in other areas at 30 years’ follow‑up.[9] It has been reported that, on an average, a women with onset of the illness at 25 years of age may lose 9 years of life, 12 years of normal health, and 14 years of effective functioning without sufficient treatment.[10] De Lisio et al. reported disruption in work and leisure, particularly in aspects requiring personal initiative that remained abnormal well into the inter episodic phase following a depressive episode.[11] Social maladjustment and incapacity to enjoy leisure time are also common.[12]

The two affective disorders, major depressive disorder and bipolar disorders were associated with the large decrements in functioning. Bipolar disorder was particularly strongly associated with having missed time at work.[13] Chaudhury et al. used Indian Disability Evaluation and Assessment Scale (IDEAS) for 228 psychiatric patients of whom 30 patients were diagnosed as bipolar disorder. In BPAD patients all the core areas of functioning such as self‑care, interpersonal relations, communication and understanding, and work were affected.[14]

Aims1. To study the sociodemographic variables among the

present study population2. To compare the age of onset of illness with the

disability in patients3. To correlate the duration of illness with disability

among the patients4. To study the correlation between current episode of

illness with the disability experienced.

METHODOLOGY

This is a cross‑sectional hospital‑based study. The study was conducted in the Inpatient Department of Psychiatry, S. V. S Medical College and Hospital. This is a tertiary care hospital, providing specialist clinical care to Mahabubnagar

and adjoining districts. The present study was conducted for 6 months, i.e. from November 1, 2016, to April 30, 2017. The study sample was collected from patients admitted for BPAD and their caregivers. Patients were selected consecutively. The study sample consisted of seventy patients diagnosed to have BPAD and their respective caregivers.

Patients fulfilling the selection criteria were approached, and informed consent was obtained. Clinical and sociodemographic details of patients and their caregivers were collected using a semistructured pro forma. Patients were administered the IDEAS[15] to assess their disability. Assessments were cross‑sectional and nonblind. The diagnosis of BPAD is made in accordance with the International Classification of Disease‑10 criteria.[16]

Criteria for selectionInclusion criteria1. Inclusion criteria were as follows: Availability of

caregivers2. Age of patient and the caregiver should be >16 years3. Both should be physically fit to answer the questions.

Exclusion criteriaExclusion criteria were as follows:1. Patients and their caregivers taking any medication,

which can produce cognitive and other psychological defect

2. Patients and their caregivers with other comorbid general medical condition, those needing urgent attention for physical problems

3. Patients without caregivers who can give reliable and adequate information

4. Those who did not give consent for the study.

RESULTS

Table 1 Shows the sociodemographics of the patient group.

The total study sample consists of 60 patients. The mean age of patients is 33.97 ± 9.8. There is almost equal distribution of males and females. With reference to education the sample were divided into four categories, illiterate, <5 years, 6–10 years, and >10 years. Most of them are either illiterate or having <10 years of formal education.

Majority of the patients were unemployed. Depending on the family income patients were divided into four categories – <5,000 Rs per month, 5,000–10,000 Rs per month, 10,000–15,000 Rs per month, and more than 15,000 Rs per month. Majority of the patients were in the category of <10,000 Rs per month. Majority of the patients belonged to nuclear family. Majority were from the urban locality.


Archives of Mental Health | Volume 19 | Issue 1 | January‑June 2018 39

Age of onset of illness is divided into three categories as 11–20 years, 21–30 years, and above 30 years. As shown in Table 2, it is found that all the patients above 30 years have moderate disability (100%) and severe disability is more prevalent in the adolescent age group (11–20 years) of patients than in others.

Table 3 shows the correlation between the disability and duration of illness in the BPAD patients. Patients are divided into three groups basing the duration of illness as 0–10 years, 11–20 years, and >20 years. We found that

all the patients with duration of illness between 11 and 20 years and above 20 years had moderate disability and severe disability is more common in patients with duration of illness <10 years.

In Table 4, the severity of the disability is correlated with the current episode of bipolar illness. Moderate disability is more prevalent in depressive patients (90%), and severe disability is found more commonly found in patients who are in manic episode (10%) than those in depressive episode. However, the correlation is not statistically significant (P = 0.33).

DISCUSSION

Patients within the age group of 11–20 years had more disability when compared to other age groups. This finding is similar to that of Goldstein et al.[17] who in his study on bipolar disorders has observed that bipolar youth in‑episode were significantly more impaired than those in partial remission/recovery in every functional domain examined and were less satisfied with their functioning. Yet, BP youth in partial remission/recovery reported significant psychosocial impairment.

Patients who are currently in manic episode have more disability than those who are in depressive phase. Depressive episodes and symptoms, which dominate the course of BPAD‑I and BPAD‑II, are equal to or more disabling than corresponding levels of manic or hypomanic symptoms; subsyndromal depressive symptoms, but not subsyndromal manic or hypomanic symptoms, are associated with significant impairment.[18] BP‑I patients were completely unable to carry out work role functions during 30% of assessed months, which was significantly more than for UP‑MDD and BP‑II patients (21% and 20%, respectively).[19]

Allen and Allen reported that disabilities restrict performance of social roles; limit the ability of the patient to function at expected levels; and often the signal that disease exists that requires diagnosis and treatment.[20] The physical functioning of the person with psychiatric disorders is of clinical interest for several reasons. First, grave disability is a common indication for inpatient

Table 1: Sociodemographic variables in patients of bipolar affective disorderVariable BPAD (n=60), n (%)

Age (years) 33.97±9.816‑30 24 (40)31‑45 26 (43.3)>45 10 (16.7)Total 60 (100)

SexFemale 30 (50)Male 30 (50)Total 60 (100)

Education (years)Illiterate 4 (6.7)<5 8 (13.3)6‑10 28 (46.7)>10 20 (33.3)Total 60 (100)

OccupationUnemployed 32 (53.3)Employed 28 (46.7)Total 60 (100)

Family income<5000 rs/m 18 (30)5000‑10,000 rs/m 30 (50)10,000‑15,000 rs/m 10 (16.7)>15,000 rs/m 2 (3.3)Total 60 (100)

D/O/M/L (years)<10 20 (33.3)11‑20 22 (36.7)21‑30 8 (13.3)31‑40 10 (16.7)Total 60 (100)

Family typeExtended 14 (23.3)Nuclear 46 (76.7)Total 60 (100)

Locality, n (%)Urban 32 (53.3)Rural 28 (46.7)Total 60 (100)

BPAD: Bipolar affective disorder, D/O/M/L: Duration of marital life

Table 2: Comparison of age of onset of illness with disability in bipolar affective disorder patientsVariable Mild disability (%) Moderate disability Severe disability Total Statistical analysis

Age of onset of illness11‑20 2 (12.5) 12 (75) 2 (12.5) 16 (100) χ2=5.93; df=10; P=0.82321‑30 4 (11.7) 28 (82.5) 2 (5.8) 34 (100)>30 0 10 (100) 0 10 (100)Total 6 (10) 50 (83.3) 4 (6.66) 60 (100)


40 Archives of Mental Health | Volume 19 | Issue 1 | January‑June 2018

psychiatric admission. Second, physical limitations may be inappropriately attributed to medical rather than psychiatric problems by the patient and health‑care providers. Third, limitation in physical functioning affects patients’ choice of mental health‑care provider (General Medical vs. Mental Health Specialist).[21]

Several psychiatric diagnoses were associated with limitation in physical functioning. The largest effects were for affective disorder, particularly major depression.

Mental illness was recognized as one of the causes of disability in an Act passed by the government of India. This act known as Persons with Disabilities Act was enacted in 1995. It came into force from February, 1996.[22] Sanderson and Andrews found that disability was significantly greater among participants with current psychiatric diagnoses and disability varied by type of disorder. Disorders found to be independently associated with disability were depression, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, alcohol dependence, and drug dependence.[23]

BPAD has been found to be associated with the following types of disability: Increased suicidal behavior, higher unemployment, higher dependence on public assistance, lower annual income, increased work absenteeism owing to illness, decreased work productivity, poorer overall functioning, lower quality of life, and decreased lifespan.[1] Chaudhury et al. found that patients having BPAD were disabled in the following cores of functioning: Self‑care, interpersonal relations, communication, and understanding and work.[14]

Depressive disorders have been associated with a larger number of disability days and poorer role functioning than several common general medical diseases – arthritis, hypertension, and diabetes.[24] It is estimated that approximately 60%–80% of those diagnosed with bipolar

disorder will respond to treatment and of the total affected 15% will commit suicide during the course of their illness.[25]

Robb et al. administered Illness Intrusiveness Rating Scale on 68 bipolar patients. The most highly disrupted domains were self expression, self‑improvement, family relationships, social relationships, and work. Moderately affected domains included financial situation, marital relations, sex life, active recreation, health and diet. Least affected life domains were passive recreation, religious expression, and community and civic involvement.[26]

CONCLUSIONS

1. The mean age of patients is 33.97 ± 9.8 with almost equal prevalence among both the genders

2. Most of them had the years of education between 5 and 10 years. Majority of the patients were unemployed, having a monthly income of <10,000 Rs per month. Many are living in nuclear families and were hailing from urban community

3. Patients falling in the age group of 11–20 years were experiencing severe disability

4. Severe disability is seen where the duration of illness <10 years

5. Among depressive patients, the disability is found to of moderate level whereas patients who have a current manic episode experienced severe disability.

Limitations1. The time‑bound nature of the study dictated a small

sample size2. Restricted nature of sample means that the findings

are not readily applicable to other population3. Assessment was cross‑sectional and nonblind4. Those patients who did not/never attend OPD were

obviously out of study5. On direct enquiry, there could be chances of wrong

information

Table 3: Correlation of duration of illness with disability in bipolar affective disorder patientsVariable Mild disability (%) Moderate disability (%) Severe disability (%) Total (%) Statistical analysis

Total duration of bipolar illness0‑10 6 (13.6) 34 (77.2) 4 (9.09) 44 (100) χ2=10.7; df=8; P=0.21911‑20 0 14 (100) 0 14 (100)>20 0 2 (100) 0 2 (100)Total 6 (10) 50 (83.3) 4 (6.66) 60 (100)

Table 4: Correlation of current episode with disability in bipolar affective disorder patientsVariable Mild disability (%) Moderate disability (%) Severe disability (%) Total (%) Statistical analysis

DiagnosisDepression 2 (10) 18 (90) 0 20 (100) χ2=2.16; df=2; P=0.33Mania 4 (10) 32 (80) 4 (10) 40 (100)Total 6 (10) 50 (83.3) 4 (6.66) 60 (100)


Archives of Mental Health | Volume 19 | Issue 1 | January‑June 2018 41

6. Several factors such as copying and expressed emotions were not assessed.



REFERENCES

1. Judd LL, Akiskal HS, Schettler PJ, Endicott J, Leon AC, Solomon DA, et al. Psychosocial disability in the course of bipolar I and II disorders: A prospective, comparative, longitudinal study. Arch Gen Psychiatry 2005;62:1322‑30.

2. Rihmer Z, Angst J. Mood disorders: Epidemiology. In: Sadock BJ, Sadock VA, editors. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 1575‑81.

3. Dube KC. A study of prevalence and biosocial variables in mental illness in a rural and an urban community in Uttar Pradesh – India. Acta Psychiatr Scand 1970;46:327‑59.

4. Trivedi S, Chandrashekaran R, Venugopalan M. An Epidemiologic Study of Psychiatric Morbidity in Rural Area of Pondicherry. Abstracts 41stannual Conference of Indian Psychiatric Society; 1988.

5. Wilder CS. Health Characteristics of Persons with Chronic Activity Limitation: Data from the National Health Survey, Series 10, Number 112: Department of Health, Educational and Welfare publication HRA77‑1539. Rockville MD: National Center for Health Statistics; 1976.

6. Stewart AL, Ware JE Jr., Brook RH. Advances in the measurement of functional status: Construction of aggregate indexes. Med Care 1981;19:473‑88.

7. Manning WG, Newhouse JP, Ware JE. Beyond excellent, good, fair, poor, in economic aspects of health. In: Fuchs VR, editor. The Status of Health in Demand Estimation. Chicago: University of Chicago Press; 1982.

8. Wilson RW, Drury TF. Interpreting trends in illness and disability: Health statistics and health status. Annu Rev Public Health 1984;5:83‑106.

9. Tsuang MT, Woolson RF, Fleming JA. Long‑term outcome of major psychoses, I: schizophrenia and affective disorders compared with psychiatrically symptom free surgical conditions. Arch Gen Psychiatry 1979;39:1295‑1301.

10. Medical Practice Project. A State‑of‑the Science Report for the Office of the Assistant Secretary for the US Department of Health, Education Welfare Baltimore; 1979.

11. De Lisio G, Maremmani I, Perugi G, Cassano GB, Deltito J, Akiskal HS, et al. Impairment of work and leisure in depressed outpatients. A preliminary communication. J Affect Disord 1986;10:79‑84.

12. Perugi G, Maremmani I, McNair DM, Cassano GB, Akiskal HS. Differential changes in areas of social adjustment from depressive episodes through recovery. J Affect Disord 1988;15:39‑43.

13. Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG, et al. Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry 1997;154:1734‑40.

14. Chaudhury PK, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2006;48:95‑101.

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16. World Health Organization. The ICD‑10 Classification of Mental and Behavioural Disorder, Tenth Revision. Geneva: World Health Organization; 1992.

17. Goldstein TR, Birmaher B, Axelson D, Goldstein BI, Gill MK, Esposito‑Smythers C, et al. Psychosocial functioning among bipolar youth. J Affect Disord 2009;114:174‑83.

18. Judd LL, Akiskal HS. The prevalence and disability of bipolar spectrum disorders in the US population: Re‑analysis of the ECA database taking into account subthreshold cases. J Affect Disord 2003;73:123‑31.

19. Judd LL, Schettler PJ, Solomon DA, Maser JD, Coryell W, Endicott J, et al. Psychosocial disability and work role function compared across the long‑term course of bipolar I, bipolar II and unipolar major depressive disorders. J Affect Disord 2008;108:49‑58.

20. Allen CK, Allen RE. Cognitive disabilities: Measuring the social consequences of mental disorders. J Clin Psychiatry 1987;48:185‑90.

21. Ware JE Jr., Manning WG Jr., Duan N, Wells KB, Newhouse JP. Health status and the use of outpatient mental health services. Am Psychol 1984;39:1090‑100.

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24. Goodwin FK, Jamision K. Manic‑Depressive Illness. New York: Oxford University Press; 1990.

25. Robb JC, Cooke RG, Devins GM, Young LT, Joffe RT. Quality of life and lifestyle disruption in euthymic bipolar disorder. J Psychiatr Res 1997;31:509‑17.

26. Robb JC, Cooke RG, Devins G, Young LT, Joffe RT. Quality of life and lifestyle disruption in euthymic bipolar disorder. J Psychiatry Res 1997;31:509‑17.


Chronic pain and psychological distress among adults in Udupi

Paramjot Panda, Suchismita Panda1

Department of Public Health, Manipal University, Manipal, Karnataka, 1Department of Clinical Psychology, Government College, Bhawanipatna, Odisha, India

INTRODUCTION

Psychological distress (PD) is a major global public health issue, both because of the relatively high prevalence ranging from 2% to 15% and because it is associated with substantial disability.[1] Rated as the fourth leading cause of disease burden in 2000, PD accounted for 4.4% of total disability-adjusted life years.[2] It is also responsible for the most significant proportion of disease burden

attributable to nonfatal health outcomes, which account for almost 12% of total years lived with disability worldwide.[3] Without treatment, PD has the tendency to assume as a chronic course. Furthermore, recurrent PD is to be associated with increasing disability.[4,5] The comorbidity of PD with chronic physical diseases (CPD) such as arthritis and diabetes is well recognized in developed countries.[6,7] Numerous epidemiological studies have shown that there is an increased risk of having major PD in people with

Background: Depression is an important public health problem and one of the leading causes of disease burden worldwide. Depression is often comorbid with other chronic diseases and can worsen their associated health outcomes. Few studies have explored the effect of depression alone or as comorbidity, with chronic pain.Objective: The objective of this study was to study the prevalence and pattern of sociodemographic characteristics of persons with depression and chronic pain residing in the Udupi taluk, Karnataka, India.Methodology: This cross-sectional study included 360 participants of above 18 years of age. The participants were recruited using simple random sampling technique from January 2017 to June 2017. Descriptive and analytical methods were used to estimate the prevalence and to identify the associated disorders.Results: It was observed during the study that prevalence of psychological distress (PD) was (58.88%). Majority of the females had moderate-to-severe PD (55.66%). The age group of 35–50 years (36.97%) had moderate-to-severe PD. The other psychiatric disorder associated with chronic pain was somatic dysfunction (27.8%), anxiety (26.9%), social dysfunction (33.8%), and depression in (11.5%).Conclusion: Depression produces the greatest decrement in health compared to the chronic physical disease. These results indicate the urgency of addressing depression as a public health priority to reduce disease burden and disability and to improve the overall health of populations.

Keywords: Adults, chronic pain, cross-sectional, risk factors

Abstract



DOI:10.4103/AMH.AMH_11_18

Address for correspondence: Mr. Paramjot Panda, Department of Public Health, Manipal University, Manipal, Karnataka, India. E‑mail: [email protected]

How to cite this article: Panda P, Panda S. Chronic pain and psychological distress among adults in Udupi. Arch Ment Health 2018;19:42-6.



Original Article

Panda and Panda: Chronic pain and psychological distress


one or more chronic diseases.[8,9] PD is more prevalent in chronic pain patients (CPPs) than in the general population as a consequence of the presence of chronic pain. The degree to which these state of comorbid exist at the Asia-specific region and in India has not been reported. According to studies, 2%–4% of persons in the community, 5%–10% of primary care patients, and 10%–14% of medical inpatients suffer from major PD.[8] Studies done in primary care setup in India, however, have estimated the prevalence rate of depression as high as 21%–40%. Furthermore, with a growing adult population, and the associated increase in the prevalence of chronic medical conditions, a concomitant rise in the incidence of PD is to be expected.[9] In fact, projections indicate that after heart disease, PD is predictable to become the second foremost cause of disease burden by the year 2020.[10] The increasing prevalence of CPD and PD leads to the question of how these disorders compare regarding their effect on overall individual health. The presence of self-reported CPD such as angina, arthritis, asthma, and diabetes has been associated with reduced health-related quality of life scores.[11-13] Lower health status has been reported in depression patients than in those without depression, and this state is unequally distributed across population groups.[8,14] Effects of PD have also been studied about a loss of productivity and reduced health-related quality of life. Despite this evidence, PD, such as other mental disorders, is often not deemed to be on a par with other chronic physical health conditions regarding its effect on overall health.[15] This understanding is perhaps one of the underlying reasons behind the lack of parity between mental and physical disorders regarding access to health care. The present population study attempts to study sociodemographic characteristics of PD in persons with chronic pain in general population through door-to-door survey in Udupi, Karnataka.

METHODOLOGY

Study design, settings, and eligibility criteria for selecting participantsA community-based cross-sectional study was conducted among randomly selected adult dwellers of Udupi Taluk in Udupi district of Karnataka, India. Participants of age range from 18 to 60 years were recruited from January 2017 to June 2017.

Data collection methodsA semi-structured questionnaire from survey of chronic pain in Europe and community-oriented program for control of rheumatic disease questionnaire was used for data collection. The tool was modified and validated by the experts in the field for use of the tool in the Indian setting. The questionnaire had

domains such as sociodemographic characteristics and chronic pain assessment. The PD among chronic pain individual was assessed using the General Health Questionnaire (GHQ) (28), which is a standardized questionnaire used to assess the PD. It contains 28 items from the original GHQ-28, across all dimensions and comprises domains such as somatic dysfunction, anxiety, social dysfunction, and depression which were used to collect the data.

Sampling technique and sample sizeSingle-stage cluster sampling technique was used in the study by considering each ward of Udupi taluk as a cluster. The list of wards (35 in number) which were procured from Udupi city municipal council was used as the sampling frame. A sample of each ward was obtained through probability proportionate to sampling (PPS) to sample size. Using PPS technique, the total number of participants from each ward was selected. The present study included participants of all proportion of specific age range from 18 to 60 until the desired sample size was obtained. A total of 360 participants were included in the study.

AnalysisThe IBM, Version 16.0. Chicago, Statistical Package for Social Sciences SPSS Inc. for Windows was used to analyze the data. Through descriptive statistics, sociodemographics were expressed as frequencies and percentages.

RESULTS

The present study was conducted among 360 randomly selected adult’s dwellers of urban Udupi taluk.

Table 1 describes the sociodemographic characteristics of the participants. Majority of the participants (31.6%) belonged to 51–60 years of age group. The number of participants was equal among males and females. Most of the study participants were Hindus (68.1%), almost 81.4% were currently married, 35.8% had primary school education, and more than half of the study participants (55.3%) belonged to the annual income category of Rs. 50,000 to Rs. 100,000. The major two sites of pain reported by males were knees (43.2%) and low back (33.6%), whereas females reported pain at the following sites such as low back (34.3%), wrist (29.3%), and knees (29.3%). The prevalence of PD was found to be 58.88% as depicted in Table 2.

In addition, females were more prone to PD as depicted in Table 3.

Furthermore, other psychological disorders associated with chronic pain and most of the participants were having social dysfunction 72 (33.8%) as depicted in Figure 1.



DISCUSSION

The range of pain experiences is wide and diverse. An individual’s response to chronic pain reflects characteristics of the pain and the person’s thoughts and behavior developed during the sequence of the sickness, which are subject to positive and negative reinforcement.[16] Major depression is the most common mental illness associated with chronic pain.[17] Hence, the present study was carried out using household survey in Udupi, Karnataka, to see the relationship between chronic pain and depression in general population. Chronic pain is a common experience and is a source of economic burden for the society. Global prevalence rates of chronic pain (International Association of Study Pain criteria specifies the duration of at least 6 months) range from 11.5% to 55.2%,[18] with a weighted mean prevalence of 35.5% across the nation.[19] The present study reported PD among the study patients with

chronic pain which was 58.8%. Another study indicated that 30% of patients had the major depressive syndrome and 70.1% of suicidal thoughts among individuals with chronic pain in a clinic in Tamil Nadu. These patients were dependent on medications and on caregivers contributing to the development of behavioral patterns of general inactiveness. Thus, due to these inter-related factors, CPPs were subjected to disabilities.[20]

In addition to the negative psychological and physiological effects, pain if not managed properly can impose a heavy economic burden. In adding to lost productive time, chronic pain increases healthcare utilization owing to more regular primary care appointments and hospital admissions (a two-fold increase) as well as emergency department visits (a five-fold increase), as compared to individuals without chronic pain.[21] Although the high variation of chronic musculoskeletal pain is evident in different regions of the world, from the clinical chapters, it emerges clearly that the women patients have higher odds of suffering from pain and PD than men.[20,22] Women in the present study also had a higher risk of both moderate and severe PD than men, and it is not unexpected as advancing age, coupled with menopausal decrements of bone health exacerbates pain. In India, every third woman is osteoporotic and consequently, osteoporosis-related high fracture risk, and declining bone mineral density (BMD) at forearm, neck, and lumbar spine worsen the propensity of musculoskeletal pain. It has also been substantiated by other population-based cross-sectional studies that women often have more musculoskeletal pain problems and PD than men.[19,21]

Epidemiological studies have derived the inverse relationship between socioeconomic status, musculoskeletal pain, and PD. British cohort study had reported that the lowest social class had three-fold increased risk of widespread chronic pain associated PD in comparison to

Table 1: Sociodemographic characteristics of the study participants (n=360)Variables Category Frequency (%)

Age group (years) 18-30 74 (20.6)31-40 92 (25.6)41-50 80 (22.2)51-60 114 (31.6)

Gender Male 180 (50)Female 180 (50)

Religion Hindu 245 (68.1)Muslim 59 (16.4)Christian 49 (13.6)Jain 7 (1.9)

Marital status Unmarried 53 (14.7)Married 293 (81.4)Separated 14 (3.9)

Educational level University graduate 54 (15)Higher secondary (11th-12th) 47 (13.1)High school (8th-10th) 46 (12.8)Primary school (1st-7th) 129 (35.8)No schooling 84 (23.3)

Annual income (rupees)

50,000-100,000 199 (55.3)100,001-150,000 60 (16.7)150,001-200,000 67 (18.6)200,000-250,000 15 (4.2)No income 19 (5.3)

Table 3: Association between psychological distress and genderGender Psychological distress Pa

Yes (n=212) No (n=148)

Female 118 (55.66) 62 (41.89) 0.032Male 94 (44.33) 86 (58.11)Total 212 (100) 148 (100)aChi-square test for association

Figure 1: Psychiatric disorders coexist with chronic pain

Table 2: Prevalence of psychological distressSex Mild, n (%) Moderate, n (%) Severe, n (%)

Male 19 (40.42) 56 (43.41) 19 (52.77)Female 28 (59.58) 73 (56.59) 17 (47.23)Total 47 (100) 129 (100) 36 (100)



the highest social class.[23] Another study had reported that patients living in less affluent areas have higher chances of chronic widespread pain, physical disability, mental distress, and low life satisfaction in comparison to patients living in affluent areas.[24] The effect of pain on PD and vice versa was not easy to understand due to their usual coexistence and bidirectional relationship. It has been observed that pain threshold was reduced in patients having PD whereby somatic preoccupation may be the primary symptom. Almost 50% of the depressed patients suffering from depression report pain in their lifetime. In the primary care setting, the complex coexistence of pain and PD is largely overlooked, and most of the times, PD is considered as an artifact of musculoskeletal pain, which may lead to poor prognosis, misdiagnosis, and under-treatment of existing pain.[20]

CONCLUSION

The present research revealed that majority of the participants in Udupi taluk had a higher prevalence of PD with chronic pain which was influenced by sedentary lifestyle, nature of job, depression, and poor sleep irrespective of the other risk variables. The results suggest that in primary care settings for the management of PD and pain, these significant variables may coexist, and therefore, should be identified and treated simultaneously. Patients with chronic pain had a moderate-to-severe level of PD along with other psychiatric disorder such as somatoform dysfunction, anxiety, social dysfunction, and depression which has a major impact on the individual’s quality of life. The findings reinforce the importance of morbidities in adult’s health as pain is the most common and neglected part of health. Morbidities need more attention to improve the well-being of individuals to aim for a healthy society for a better tomorrow.

Ethical issuesEthical clearance for the study was obtained from the Institutional Ethics Committee (IEC), (IEC 879/2016). Participation was voluntary and informed consent was obtained from all the participants after the purpose of the study was explained to them using a participant information sheet. Confidentiality of the data was guaranteed.

AcknowledgmentThe authors would like to thank all the participants who participated in this study my parents to support me. Furthermore, we would like to express our gratitude to the Department of Public Health, Manipal University, Manipal, Karnataka, India.

Financial support and sponsorshipThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


REFERENCES

1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006;3:e442.

2. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al. Disease Control Priorities in Developing Countries, Second Edition. Washington, DC: World Bank and Oxford University Press; 2006.

3. Kostanjsek N, Good A, Madden RH, Üstün TB, Chatterji S, Mathers CD, et al. Counting disability: Global and national estimation. Disabil Rehabil 2013;35:1065-9.

4. Solomon DA, Keller MB, Leon AC, Mueller TI, Lavori PW, Shea MT, et al. Multiple recurrences of major depressive disorder. Am J Psychiatry 2000;157:229-33.

5. Andrews G. Should depression be managed as a chronic disease? BMJ 2001;322:419-21.

6. Cassano P, Fava M. Depression and public health: An overview. J Psychosom Res 2002;53:849-57.

7. Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis 2005;2:A14.

8. Noël PH, Williams JW Jr., Unützer J, Worchel J, Lee S, Cornell J, et al. Depression and comorbid illness in elderly primary care patients: Impact on multiple domains of health status and well-being. Ann Fam Med 2004;2:555-62.

9. Grover S, Dutt A, Avasthi A. An overview of indian research in depression. Indian J Psychiatry 2010;52:S178-88.

10. Murray CJ, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from deceases, injuries and risk factors in 1990 and projected to 2010. Vol. 1. Boston, USA: Harvard University Press; 1996. p. 1-35.

11. Ibrahim N, Din NC, Ahmad M, Ghazali SE, Said Z, Shahar S, et al. Relationships between social support and depression, and quality of life of the elderly in a rural community in Malaysia. Asia Pac Psychiatry 2013;5 Suppl 1:59-66.

12. Charles B, Jeyaseelan L, Pandian AK, Sam AE, Thenmozhi M, Jayaseelan V, et al. Association between stigma, depression and quality of life of people living with HIV/AIDS (PLHA) in South India – A community based cross sectional study. BMC Public Health 2012;12:463.

13. Menon B, Nayar R, Kumar S, Cherkil S, Venkatachalam A, Surendran K, Deepak K S. Parkinson's disease, depression, and quality-of-life. Indian J Psychol Med 2015;37:144-8.

14. Panda P, Vyas N, Dsouza SM, Boyanagari VK. Determinants of chronic pain among adults in urban area of Udupi, Karnataka, India. (in Press) Clin Epidemiol Glob Health 2018;1. [Doi. 10.1016/j.cegh. 2018.03.002].

15. Sahoo S, Khess CR. Prevalence of depression, anxiety, and stress among young male adults in india: A dimensional and categorical diagnoses-based study. J Nerv Ment Dis 2010;198:901-4.

16. Caltabiano ML, Byrne D, Sarafino EP. Health Psychology: Biopsychosocial Interactions, an Australian Perspective. 2nd ed. Brisbane, Qld: John Wiley & Sons; 2008.

17. Demyttenaere K, Bruffaerts R, Lee S, Posada-Villa J, Kovess V, Angermeyer MC, et al. Mental disorders among persons with chronic back or neck pain: Results from the world mental health surveys. Pain 2007;129:332-42.

18. Merskey H, Bogduk N. Classification of Chronic Pain. IASP Pain



Terminology; 1994. p. 240.19. Yamada K, Matsudaira K, Imano H, Kitamura A, Iso H. Influence

of work-related psychosocial factors on the prevalence of chronic pain and quality of life in patients with chronic pain. BMJ Open 2016;6:e010356.

20. Muthunarayanan L, Ramraj B, Russel J. Prevalence of prediabetes and its associated risk factors among rural adults in Tamil Nadu. Arch Med Heal Sci 2015;3:178.

21. Dhillon H, Khullar S, Kaur G, Sharma R, Mehta K, Walia JP, et al. Prevalence and predictors of chronic musculoskeletal pain in the population of Punjab. IJHSR 2016;6:248-58.

22. Vieira EB, Garcia JB, Silva AA, Araújo RL, Jansen RC, Bertrand AL, et al. Chronic pain, associated factors, and impact on daily life: Are there differences between the sexes? Cad Saude Publica 2012;28:1459-67.

23. Macfarlane GJ, Norrie G, Atherton K, Power C, Jones GT. The influence of socioeconomic status on the reporting of regional and widespread musculoskeletal pain: Results from the 1958 British Birth Cohort Study. Ann Rheum Dis 2009;68:1591-5.

24. Ni Mhurchu C, Rodgers A, Pan WH, Gu DF, Woodward M; Asia Pacific Cohort Studies Collaboration. Body mass index and cardiovascular disease in the Asia-Pacific Region: An overview of 33 cohorts involving 310 000 participants. Int J Epidemiol 2004;33:751-8.


Anorexia nervosa in rural South IndiaKeya Das, K. S. Ashok1

Department of Psychiatry, Sagar Hospitals, Bengaluru, 1Department of Psychiatry, Mandya Institute of Medical Sciences, Mandya, Karnataka, India

INTRODUCTION

A postal survey of 30 cases of Anorexia Nervosa was reported from Malaysia (19 Chinese, 8 Indians, 2 Eurasians and 1 Malay).[1] A similar postal survey in Japan by Suematsu et al. found 1312 cases of Anorexia Nervosa, a doubling of prevalence in 10 years.[2] Ong et al. reported 7 cases of Anorexia Nervosa in Singapore.[3] AN is almost absent in the Chinese population with only a few cases being reported from Hong Kong.[4] Three cases of Anorexia Nervosa have been reported in Vietnamese refugees.[5] The exact prevalence of Anorexia Nervosa in the Indian subcontinent has not been explored. However, there have been sporadic case reports from the Indian subcontinent and Pakistan. Most of such findings are confined to the affluent strata

and those with a cosmopolitan background.[6] We present a case of contrasts regarding cultural views and geographical influences as against the norm of anorexia nervosa theories thus far. As per our findings, this is the first presentation of anorexia nervosa among the rural Indian subcontinent.

CASE REPORT

Miss X, aged 12 years and 8 months, Grade 6 student, elder child of two siblings hailing from rural district and belonging to Hindu faith, of traditional family sensibilities was referred by the Pediatrician because of concerns about her insidious weight loss for which no organic cause was found. Thorough investigations with the suspicion of tuberculosis, abdominal malignancies, endocrine disorders were conducted and were found to be well within normal

Anorexia Nervosa, an eating disorder having first been identified in the 17th Century Europe has been considered a western syndrome with emphasis on slimness as a measure of feminine beauty. Global development and rapid changes in South-East Asian countries in economy, mindsets, and Adoption of Western attitude has occurred there have been sporadic reports of Anorexia Nervosa in the past few years in India mostly in cities. Our case report digresses from the familiar theory of Anorexia Nervosa being a westernized concept in presenting a case from Rural South India. We report of a 12-year-old girl child from rural district, South India, belonging to a traditional South Indian family of middle class status, presented with somatic complaints of pain abdomen and vomiting with background of progressive weight loss over 3 months with amenorrhea of 3 months, precipitating factor of comments from relatives about weight gain and menarche. Diagnosis of Anorexia Nervosa was made, with Body Mass Index 14.9. A multidisciplinary approach to treatment was commenced. Authors aim to point out the need to screen for eating disorders irrespective of patients’ geographic or cultural affiliations to ensure prompt intervention.

Keywords: Anorexia nervosa, culture, geography, rural, South India

Abstract



DOI:10.4103/AMH.AMH_17_18

Address for correspondence: Dr. Keya Das, G 02, Tuscan East Apartments, Lazar Road, Cox Town, Bengaluru ‑ 560 042, Karnataka, India. E‑mail: [email protected]

How to cite this article: Das K, Ashok KS. Anorexia nervosa in rural South India. Arch Ment Health 2018;19:47-9.



Case Report

Das and Ashok: Case of anorexia nervosa in rural India


limits. In the months before the referral, the patient had lost weight significantly for the past 2½ months and reported to be eating sparingly at home. On a daily basis, the patient was reported to be eating only 1 meal per day, which consisted of a small bowl of rice with lentils. Weight loss over the past 2½ months was 13 kg. Parents reported that the child would at times claim she has eaten elsewhere to avoid eating with the family at mealtimes and when insisted on would get into frequent arguments with family members. The family also mentioned her concerns regarding a need to “remain slim unlike her mother” and her preoccupation with body image post her attaining puberty 10 months back.

There was a history of excessive exercise and overt indulging in sports activities for the past 2 months; often, the adolescent was found checking her weight in the weighing scale kept in the retail shop owned by her parents. There was no history of laxative abuse or self-induced vomiting. Menstruation which had commenced 10 months earlier, was initially regular but had become irregular for the past 4 months with amenorrhea of 3 months. Parents described her as a highly organized child, a good pupil and ambitious about school performance. During the past month, the parents had noticed her progressive weight loss and frequent days wherein she was easily fatigued. The reason for pediatric help being sought was that the child developed vomiting and pain abdomen lasting for 3 days, associated with exhaustion and was admitted for the same.

On examination, Miss X was stunted as per her age, asthenic and dehydrated. Her Body Mass Index was 14.9, with a body weight of 30.05 kg and height of 142 cm. She had cold extremities, tachycardia with poor peripheral pulses, and a low-blood pressure of 96/60. Secondary sexual characteristics were noted to be minimal. Blood investigations showed her to be anemic (Hb 8.2), with borderline calcium levels and hypokalemia.[7]

Detailed evaluation established a better rapport with the child. She admitted to “Dieting” and checking her weight more than before as “people” had warned her that she might become obese like her mother after puberty. Further explanations from the child revealed, by “people” she meant extended female family members, i.e., maternal aunts and cousins who discussed her possibility of gaining weight after menarche like her mother. Family psychodynamics revealed that the child was well adjusted at home, had a good rapport with parents and younger sibling. However, the mother did hint towards some amount of sibling rivalry regarding academic performance between both the children.

Clinical depression was ruled out, with no suicidal ideations or Deliberate Self-Harm Behaviour following which a diagnosis of Atypical Anorexia Nervosa was made (according to ICD-10). The general health questionnaire and the eating disorder examination questionnaire were administered. In addition to the pediatric management of maintaining her electrolyte levels, and treatment commencement of anemia with iron and folic acid tablets, psychiatric management was initiated with a focus on weight gain in a gradual manner. Psychoeducation about the disorder was given to the child and parents, myths and misconceptions about body image and menstruation were addressed. Nutritional rehabilitation was planned, where she was asked to maintain a dairy about her intake of food. Initiation of a low dose psychotropic was discussed with patient and family. However as they chose not to opt for medication, it was withheld. She was encouraged to eat food with high caloric value and introducing certain food items into her meal was planned with the patient. Parents were asked to keep a watch for possible purging behavior. Improvement in weight was noted by 1.5 kg at the end of 10 days of hospital stay. The patient was discharged with a diet chart, maintenance of meal diary, with subsequent follow-up at 2 weekly intervals with a plan to initiate cognitive-behavioral therapy for distortion in body image.

DISCUSSION

The past decades have seen a rise in the cases of anorexia nervosa in the Indian subcontinent. Early age of onset from 12 to 20 years is the most common presentation.[8] With this case report, we hope to bring to the notice that the earlier notion of Anorexia Nervosa being an urban concept is now changing and seeping into the rural areas as well or has gone undetected in the past.

Recent reports suggest a rise in the clinical cases of Anorexia Nervosa in India,[7] with the cases cropping up in urban population and more often only when the Somatic complaints are severe enough to warrant medical attention. Reports from Asian subcontinent and Pakistan found that there was evidence that most westernized girls were at great risk of developing an eating disorder. There was also support for the hypothesis that the effects of Westernization on eating attitudes were mediated through greater dissatisfaction with body shape.[6] They expected to find an increased incidence of eating disorders with the widespread acquisition of western manners, customs, styles, and perspectives.

Cultural factors in the etiology of Eating Disorders have been clearly operative. However, this case report

Das and Ashok: Case of anorexia nervosa in rural India


along with others from Asian Subcontinent disputes the notion that Anorexia Nervosa is restricted only to the Caucasian individuals or just to the urban-westernized mindset.[6] In our case study, the child came from a traditional south Indian household of India and hailing from a rural district. Several factors could be considered in the etiology of pathogenesis, particularly the developmental theory which states the inability to cope with developmental demands of Adolescence in keeping with Crisp’s view.[9]

Characteristically, the child had attained puberty only 10 months before the development of symptoms. This could be considered a significant life event, which is in keeping with theories of onset of psychiatric disorders, including Eating Disorders.[6] The emphasis on body image especially on the female gender is as prevalent in the Indian culture as it is in other ethnic/racial groups, and this case evidences the same with the child experiencing a need to “fit in” to extended family expectations.

The child presented with somatic complaints for which multiple specialist opinions were sought to discern the underlying reason for symptomatology. As no definitive organic condition was arrived at, the case was referred for psychiatric evaluation. Report of this specific case hopes to bring to the attention of pediatricians, general practitioners, and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would manifest somatic conditions similar to the reported case. It also points to the need to keep an open mind as to the possibilities of an eating disorder in children and adolescents irrespective of geographical or racial distribution. A need for dispelling myths and misconceptions regarding healthy body proportions as per gender, age, race, and association with height is essential to combat the development of eating disorders. Further exploration of the prevalence of eating disorders in the Indian subcontinent may shed light as to the real extent

of the disorder prevailing in the nation. Consent has been taken from Patient and Family, with care not to disclose the patients identity.

Declaration of patient consentThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



REFERENCES

1. Buhrich N. Frequency of presentation of anorexia nervosa in Malaysia. Aust N Z J Psychiatry 1981;15:153-5.

2. Suematsu H, Ishikawa H, Inaba Y. Epidemiological studies of anorexia nervosa. Shinshin Igaku Psychosom Med 1986;26:53-8.

3. Ong YL, Tsoi WF, Cheah JS. A clinical and psychosocial study of seven cases of anorexia nervosa in Singapore. Singapore Med J 1982;23:255-61.

4. Lee S, Chiu HF, Chen CN. Anorexia nervosa in Hong Kong. Why not more in Chinese? Br J Psychiatry 1989;154:683-8.

5. Kope TM, Sack WH. Anorexia nervosa in Southeast Asian refugees: A report on three cases. J Am Acad Child Adolesc Psychiatry 1987;26:795-7.

6. Imran A, Ashraf N. Anorexia nervosa in a Pakistani adolescent girl: A case report with literature review of anorexia nervosa in Asia. Annals 2008;14:156-8.

7. Srinivasa P, Chandrashekar M, Harish N, Gowda MR, Durgoji S. Case report on anorexia nervosa. Indian J Psychol Med 2015;37:236-8.

8. Mammen P, Russell S, Russell PS. Prevalence of eating disorders and psychiatric comorbidity among children and adolescents. Indian Pediatr 2007;44:357-9.

9. Crisp AH. Anorexia Nervosa: Let Me Be. London: Academic Press; 1980.


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