R. Thara

Women with schizophrenia and broken marriages--doubly disadvantaged? Part II: family perspective.

This is a qualitative study of 76 women with schizophrenia whose marriages had broken. The sample was drawn from three different centres. Using qualitative methods of exploration, information regarding their illness, the marriage and its separation and the various consequences of this event was gathered. Many of them had not separated legally and were not receiving any maintenance from their husbands. Their concerns centred around their future, the fact they would be a burden to their ageing parents and in some cases about their children. Stigma attached to separation was as poignant as that of being mentally ill, if not more. However, a striking aspect was that even after several years of separation, these women still harboured a lot of hope that they would be able to reunite with their husbands.

PREVALENCE OF DEMENTIA IN A RURAL SETTING: A REPORT FROM INDIA

A study to estimate the prevalence of dementia in a rural population was conducted in a community located on the outskirts of Madras city in South India. Seven hundred and fifty elderly 60 years of age and older, selected using the cluster sampling technique, were interviewed using the Geriatric Mental State schedule (GMS). The prevalence of dementia was 3.5%, the percentage increasing with age. These rural prevalence estimates were higher than in urban settings (WHO multicentre study on cognitive impairment and dementia in developed and developing countries, unpublished) and male/female differences were negligible. The difficulties associated with the use of the GMS in a non‐literate rural population are discussed. The implications of these findings for Indias growing elderly population are highlighted.

Smoking in schizophrenia — all is not biological

High rate of tobacco smoking reported in schizophrenia has been related to the effect of nicotine on the neurobiology of schizophrenia. Nicotine is said to alleviate psychotic symptoms in some patients. The relationship between smoking and psychiatric status may not be simply a biological one as several sociocultural and economic factors could influence smoking behaviour. In this study in India on 286 urban male outpatients with schizophrenia, only 38% were found to be current smokers. This was significantly more than in other psychiatric patients studied (major affective disorders and non-psychotic disorders) but not medically ill controls and not higher than the rates for the general male population in India. Smokeless use of tobacco was infrequent in the study population. More than half of the patients did not experience any positive effects due to smoking. Lack of economic independence and restrictions imposed by the family appeared to be crucial factors that controlled the prevalence of smoking among schizophrenia patients. As smoking is a leading cause of preventable morbidity and mortality, there is a serious need to review the neurobiological issue of smoking in schizophrenia considering the influence culture and social practices could have upon the behaviour.

A Qualitative Study of Religious Practices by Chronic Mentally Ill and their Caregivers in South India

Background: Socio-cultural explanatory factors for mental health problems determine help seeking behaviors. The study aimed to understand the reasons mentally ill patients and their families in India choose to seek help from a religious site. Materials and methods: Persons with mental illness and their families were interviewed at religious sites using a guideline questionnaire. Issues such as significant life events, explanations for perceived abnormal behavior and reasons for choosing a specific religious site for ‘treatment’ were explored. Discussion: Seeking religious help for mental disorders is often a first step in the management of mental disorders as a result of cultural explanations for the illness. This behavior also has social sanctions.

What Is the Best Approach to Treating Schizophrenia in Developing Countries

Background to the debate: Schizophrenia affects an estimated 25 million people in low- and middle-income countries, with an average lifetime risk of about 1%. The illness is associated with excess mortality from a variety of causes. A 2001 Institute of Medicine report on mental illness in developing countries found that in 1990, over two-thirds of people with schizophrenia in these countries were not receiving any treatment (http://www.nap.edu/catalog/10111.html). The report found no evidence that the proportion of treated people in the developing world had increased since 1990. There is now a debate among mental health professionals in low-income countries over how best to improve patient care. In this article, three psychiatrists give their different viewpoints on the current status of treatment efforts for schizophrenia in the developing world and the measures that can be taken to increase the proportion of patients receiving treatment.

Community mental health in India: A rethink.

BackgroundCommunity care of the chronic mentally ill has always been prevalent in India, largely due to family involvement and unavailability of institutions. In the 80s, a few mental health clinics became operational in some parts of the country. The Schizophrenia Research Foundation (SCARF), an NGO in Chennai had established a community clinic in 1989 in Thiruporur, which was functional till 1999. During this period various programmes such as training of the primary health center staff, setting up a referral system, setting up of a Citizens Group, and self-employment schemes were initiated. It was decided to begin a follow up in 2005 to determine the present status of the schemes as well as the current status of the patients registered at the clinic. This we believed would lead to pointers to help evolve future community based programmes.MethodsOne hundred and eighty five patients with chronic mental illness were followed up and their present treatment status determined using a modified version of the Psychiatric and Personal History Schedule (PPHS). The resources created earlier were assessed and qualitative information was gathered during interviews with patient and families and other stakeholders to identify the reasons behind the sustenance or failure of these initiatives.ResultsOf the 185 patients followed up, 15% had continued treatment, 35% had stopped treatment, 21% had died, 12% had wandered away from home and 17% were untraceable. Of the patients who had discontinued treatment 25% were asymptomatic while 75% were acutely psychotic.The referral service was used by only 15% of the patients and mental health services provided by the PHC stopped within a year. The Citizens group was functional for only a year and apart from chicken rearing, all other self-employment schemes were discontinued within a period of 6 months to 3 years.There were multiple factors contributing to the failure, the primary reasons being the limited access and associated expenses entailed in seeking treatment, inadequate knowledge about the illness, lack of support from the family and community and continued dependence by the family on the service provider to provide solutions.ConclusionCommunity based initiatives in the management of mental disorders however well intentioned will not be sustainable unless the family and the community are involved in the intervention program with support being provided regularly by mental health professionals.

Role of non-governmental organizations in mental health in India.

The paucity of treatment facilities and psychiatrists in the Government sector has widened the treatment gap in mental health. Non-governmental organizations (NGOs) have played a significant role in the last few decades in not only helping bridge this gap, but also by creating low cost replicable models of care. NGOs are active in a wide array of areas such as child mental health, schizophrenia and psychotic conditions, drug and alcohol abuse, dementia etc. Their activities have included treatment, rehabilitation, community care, research, training and capacity building, awareness and lobbying. This chapter outlines the activities of NGOs in India. This is a revised version of the chapter in the book on mental health to be brought out by Government of India.

Relationship of extrapyramidal symptoms to age at onset and drug treatment in middle-aged and elderly schizophrenic patients.

The relationship between antipsychotic drugs and dyskinesias and other extrapyramidal symptoms (EPS) in schizophrenia is not simple. There is a need to study variables that may influence the occurrence of EPS in schizophrenic patients receiving drugs. The present study examined the relationship of age at onset of illness and treatment to the development of EPS in 122 middle-aged and elderly schizophrenic patients, 84 treated and 38 who had never received antipsychotic drugs. The illness had an early onset (before 45years, EOS) in 68 patients and a late onset (after 45years, LOS) in 54 patients. The patients were evaluated for dyskinesia and parkinsonism using abnormal involuntary movements scale (AIMS) and Simpson-Angus scale. The prevalence of dyskinesia and parkinsonism was similar in all the patient groups. The scores on limb-axial and severity subscales of AIMS were significantly higher in the treated than the untreated patients of the early onset group. This was not so with the late onset patients. The total parkinsonism score was higher among the treated, notably the LOS patients. The development of dyskinesia and parkinsonism in schizophrenia is possibly related to the age at onset of the illness. In late onset forms the ageing of the patient and a possible neurological abnormality related to schizophrenia might enhance the EPS-inducing effect of drugs.

Psychosocial interventions after tsunami in Tamil Nadu, India.

Any response to the mental health needs of the affected community following any disaster depends upon a number of factors, including disaster preparedness, existence of mental health services, resources in human and financial terms, along with the magnitude, cause and suddenness of the event. In India, groups of islands in the Bay of Bengal and the coast of Tamil Nadu were very badly hit. The survivors needed basic physical and emotional support. The response by two non-governmental organizations (NGOs) is described in this paper. Normalization was seen as an important first step. Using a number of training materials, volunteers were trained to deal with the mental health needs of the survivors. A consistent well resourced and accessible mental health network is necessary for appropriate intervention.

Shadows of culture in psychosis in south India: a methodological exploration and illustration.

Transcultural studies suggest a possible influence of culture on the course and outcome of schizophrenia. However, the notion of culture remains ill-defined in these studies; most often, hypotheses regarding protective factors seem to derive more from stereotyped visions of cultural differences than be empirically based. Explorative studies conducted in south India consider subjective experience as a key mediating variable between culture and course and outcome in schizophrenia. They explore patients and relatives experience and its evolution and aim at identifying the explicit and implicit references to culture throughout the narratives. Ethnographically oriented data collected through an open-ended Turning Point/Period Interview systematically reconstructs the perceived evolution of signs, coping, explanations, reactions and help-seeking from different perspectives. This paper examines the degree of convergence and divergence between narratives collected from a small sample of female schizophrenic patients and one of their relatives. A high degree of convergence at the level of symptoms and differences in their narrative construction are observed.