R. Srinivasa Murthy

Community outreach for untreated schizophrenia in rural India: a follow-up study of symptoms, disability, family burden and costs

BACKGROUND In resource-poor countries, there remains an alarming treatment gap for people with schizophrenia, particularly those living in rural areas. Decentralization of mental health services, including community-based outreach programmes, represents one obvious strategy for bringing appropriate care to these communities. This study set out to assess the costs and effects of such a programme in rural Karnataka in India. METHOD Eight rural communities were visited by an outreach team, who identified cases of drug-naive or currently untreated schizophrenia. Recruited cases were provided with appropriate psychotropic medication and psychosocial support, and after obtaining informed consent were assessed every 3 months over one and a half years on symptomatology, disability, family burden, resource use and costs. A repeated-measures analysis was carried out to test for significant change in these outcome measures over this period. RESULTS A total of 100 cases of untreated schizophrenia were recruited, of whom 28% had never received antipsychotic medication and the remaining 72% had not been on medication for the past 6 months. Summary scores for psychotic symptoms, disability and family burden were all reduced significantly, with particular improvement observed at the first follow-up assessment. Increases in treatment and community outreach costs over the follow-up period were accompanied by reductions in the costs of informal-care sector visits and family care-giving time. CONCLUSIONS Efforts to organize community-based care such as outreach services for people with schizophrenia living in more remote areas of resource-constrained countries can bring substantial benefits to patients and families alike.

A nosological study of patients presenting with somatic complaints

ABSTRACT The nosological status of patients presenting with multiple somatic complaints with reference to ICD‐9 was examined in the present study. In 22% of the cases it was not possible to arrive at a single ICD‐9 diagnosis. The majority of these cases had combinations of somatic, anxiety and depressive symptoms. Nine percent of the cases could not be given any psychiatric diagnosis using ICD‐9. These cases had very few psychological symptoms and were not identified as pscyhiatric cases by the present state examination. The various possible factors responsible for this diagnostic uncertainty have been highlighted.

Mass violence and mental health -- Recent epidemiological findings

There is growing awareness of the mental health impact of all types of mass violence. The exposure of large population groups, mostly having no mental health problems prior to the exposure, and the subsequent development, in a significant proportion of the population, of a variety of psychiatric symptoms and disorders represent both a challenge and an opportunity for psychiatrists. There is sufficient evidence from the variety of mass violence/conflict situations, that a significant proportion of the exposed population develop different mental disorders. There are vulnerable groups like women, children, widows, orphans, elderly, disabled, those exposed to severe pain and loss of body parts. There is also a consistent finding of the dose-response to the amount of trauma and the prevalence of mental disorders. There is growing recognition that there is need to consider a variety of syndromes, in addition to post-traumatic stress disorder (PTSD) like acute stress disorder (ASD), depression, complicated bereavement reactions, substance use disorders, poor physical health, fear, anxiety, physiological arousal, somatisation, anger control, functional disability and arrest or regression of childhood developmental progression. The challenge is to reach all of the ill persons and provide mental health services. The opportunity provided by this field is to develop a better understanding of issues of resilience, recovery and effectiveness of public health approaches to mental health care.There is growing awareness of the mental health impact of all types of mass violence. The exposure of large population groups, mostly having no mental health problems prior to the exposure, and the subsequent development, in a significant proportion of the population, of a variety of psychiatric symptoms and disorders represent both a challenge and an opportunity for psychiatrists. There is sufficient evidence from the variety of mass violence/conflict situations, that a significant proportion of the exposed population develop different mental disorders. There are vulnerable groups like women, children, widows, orphans, elderly, disabled, those exposed to severe pain and loss of body parts. There is also a consistent finding of the dose-response to the amount of trauma and the prevalence of mental disorders. There is growing recognition that there is need to consider a variety of syndromes, in addition to post-traumatic stress disorder (PTSD) like acute stress disorder (ASD), depression, complicated bereavement reactions, substance use disorders, poor physical health, fear, anxiety, physiological arousal, somatisation, anger control, functional disability and arrest or regression of childhood developmental progression. The challenge is to reach all of the ill persons and provide mental health services. The opportunity provided by this field is to develop a better understanding of issues of resilience, recovery and effectiveness of public health approaches to mental health care.

The International Consortium on Mental Health Policy and Services: objectives, design and project implementation

The concept of the burden of disease, introduced and estimated for a broad range of diseases in the World Bank report of 1993 illustrated that mental and neurological disorders not only entail a higher burden than cancer, but are responsible, in developed and developing countries, for more than 15% of the total burden of all diseases. As a consequence, over the past decade, mental disorders have ranked increasingly highly on the international agenda for health. However, the fact that mental health and nervous system disorders are now high on the international health agenda is by no means a guarantee that the fate of patients suffering from these disorders in developing countries will improve. In most developing countries the treatment gap for mental and neurological disorders is still unacceptably high. To address this problem, an international network of collaborating institutions in low-income countries has been set up. The establishment and the achievements of this network—the International Consortium on Mental Health Policy and Services—are reported. Sixteen institutions in developing countries collaborate (supported by a small number of scientific resource centres in industrialized nations) in projects on applied mental health systems research. Over a two-year period, the network produced the key elements of a national mental health policy; provided tools and methods for assessing a countrys current mental health status (context, needs and demands, programmes, services and care and outcomes); established a global network of expertise, i.e., institutions and experts, for use by countries wishing to reform their mental health policy, services and care; and generated guidelines and examples for upgrading mental health policy with due regard to the existing mental health delivery system and demographic, cultural and economic factors.

THE BURDEN OF MENTAL-ILLNESS ON THE FAMILY - RESULTS OF OBSERVATIONS IN 4 DEVELOPING-COUNTRIES - A REPORT FROM THE WHO COLLABORATIVE STUDY ON STRATEGIES FOR EXTENDING MENTAL-HEALTH-CARE

ABSTRACT– As part of the WHO Collaborative Study on Strategies for Extending Mental Health Care 259 families in four developing countries (Colombia, India, Sudan and the Philippines) were screened with regard to the social burden caused by mental illness of one of its members. Levels of subsistence, previous illness, financial burden, personal relations and social acceptance were studied. The social burden was greatest in the urban areas.

The Mental Health Country Profile: background, design and use of a systematic method of appraisal

This article describes the construction and use of a systematic structured method of mental health country situation appraisal, in order to help meet the need for conceptual tools to assist planners and policy makers develop and audit policy and implementation strategies. The tool encompasses the key domains of context, needs, resources, provisions and outcomes, and provides a framework for synthesizing key qualitative and quantitative information, flagging up gaps in knowledge, and for reviewing existing policies. It serves as an enabling tool to alert and inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. It provides detailed country specific information in a systematic format, to facilitate global sharing of experiences of mental health reform and strategies between policy makers and other stakeholders. Lastly, it is designed to be a capacity building tool for local stakeholders to enhance situation appraisal, and multisectorial policy development and implementation.

Training primary care medical officers in mental health care: an evaluation using a multiple‐choice questionnaire

This report aimed to evaluate the mental health knowledge of primary care medical officers following short‐term training in mental health care using a multiple‐choice questionnaire. Seventy‐eight medical officers who underwent 2 weeks’ training in mental health care were assessed using parallel forms of a standardized multiple‐choice questionnaire administered before and soon after the training. Young doctors scored significantly higher in the pretraining assessment. The medical officers demonstrated a significant gain in knowledge, although the amount of gain varied. Doctors who had relatively lower pretraining scores showed a higher gain. Six doctors (8%) showed less than acceptable posttraining scores. These doctors were older than the rest of the group. The doctors’ pretraining knowledge was best with respect to epilepsy and poorest with respect to manic‐depressive psychosis. Items pertaining to epidemiology and aetiology elicited relatively less gain than other clinical dimensions.

The appropriateness and use of focus group methodology across international mental health communities

The ability to interpret collected data across international mental health communities often proves to be difficult. The following paper reports on the use and appropriateness of focus group methodology in helping to clarify issues that could help substantiate data collection and comparison across different cultures and regions. Field tests of the focus group methodology were undertaken in different regions and this paper describes an overview of the final field test in Sofia, Bulgaria. The findings and experiences with utilizing this methodology were incorporated in subsequent data collections.

Training of primary health care medical officers in mental health care: Errors in clinical judgment before and after training

This investigation examined the nature and frequency of errors in clinical judgment that were displayed by primary health care medical officers before and after short-term training in mental health care. Thirty-nine medical officers who underwent inservice training for 2 weeks were evaluated using standardized case vignettes. Before the training, doctors displayed a sizable percentage of major and minor errors, which dropped significantly following training. Errors were not unique to psychiatric presentations alone, but occurred with respect to vignettes representing physical disorders as well. The results on the whole demonstrate a satisfactory gain in clinical skills of medical officers following the training and highlight the need for continuation of a program of this nature.

Socio‐demographic correlates of schizophrenia, affective psychoses and neuroses in a clinic in India

Of a total of 5,343 patients seen during four calendar years at the adult psychiatric outpatients’clinic of a teaching hospital in India, patients with schizophrenia, affective psychoses and neuroses were compared with one another regarding distribution of socio‐demographic variables. Women with an urban background and higher socio‐economic status were proportionately more numerous amongst neurotics. Schizophrenics were youngest and more often single. Patients with affective psychoses were older, usually married, had the lowest educational level and most often a rural background, and were from relatively lower socio‐economic strata. Also the Sikh religion and Jat caste were significantly more preponderant amongst affective psychotics. This finding is consistent with the reported distribution of ABO blood groups in affective psychotics and in Jat Sikhs, and suggests a genetic basis for the greater representation of Jats and Sikhs amongst affective psychotics.