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A cost-effective analysis of three different methods of psychiatric case finding in the general population
Abstract
A study was carried out to compare the sensitivity as well as cost of three different methods of psychiatric case detection. It was found that the simplest method, which involved interviewing about 3 per cent of the adult population, with a questionnaire taking only five minutes to complete, picked up as many adult epileptics and nearly as many psychotics as the inquiry with all the adults in the population using a sophisticated structured interview schedule. A method of medium complexity, in which the short five-minute questionnaire was given to one adult member of each family, detected in addition to all adult epileptics and psychotics, and many juvenile epileptics and mentally retarded.
The cost of the simplest method was one-ninth and that of the method of medium complexity, one-fifth of the cost of the most sophisticated method.
The method of medium complexity is recommended for use in the rural psychiatry programme of the developing countries.
... A wide spectrum of psychiatric distlirbaoce is noted in the interseizure periods among epileptics (Agnihotri et a1,1972j. the Indian Psychiatric Survey Schedule (IPSS) (Kapur et al, 1974) and (iv) 'symptoms in others' questionnaire (Isaac and Kapur, 1980) Most tech~liques available for detecting mental disorders in the general population have rhort-comings and need trained personnel. It is an epidem~ological dilemma that methods which give more reliable and valid results have proven to be extremely costly in terms 1 of time, effort and money (Sartorius, 1977). ...
... , Thus from a service point of view,inexpensive I procedures are recommended. By the use of 'symptoms in o~hers' questionnaire, Isaac et al (1980) were able to pick up all adult retarded individuals. According to them, this method Mental Health Priorities in Primary Health Care 43 is cost effective, time-saving and even nonprofessionals can be trained in administering he questionnaire. ...
... In a study (Isaac and Kapur, 1980), sensitivity as well as cost of three different methods (interviewing, questionnaire and details case history evaluation) were compared for psychiatric case detection in rural setting. The cost of the simplest method was one-ninth (interview) and that of the method of medium complexity (questionnaire), one-fifth of the cost of the most Screening for psychiatric morbidity helps to identify disease, enable initiation of treatment and intervention to reduce mortality and suffering from psychological problems. ...
... sophisticated method (case history evaluation) (Isaac and Kapur, 1980). The Health of the Nation Outcome Scale (HONOS) psychometric properties was established for routine use in mental illness service. ...
Screening for psychiatric morbidity helps to identify disease, enable initiation of treatment and intervention to reduce mortality and suffering from psychological problems. There is a dearth of such scales in India and South East Asia. The present work aims to develop and validate the NIMHANS screening tool for psychological problems in Indian context. 754 (229 normal subjects and 525 clinical subjects) were taken from the community and in-patient and out patient psychiatric setting of the hospital. Socio-demographic datasheet and the newly developed tool were administered on them. Split half reliability of the tool was 0.84. Score of 9 and above indicated presence of psychiatric distress in clinical and normal group .Discriminate validity developed with sensitivity of 0.76and specificity of 0.82.The NIMHANS screening tool for Psychological problems has a utility in screening out psychiatric distress in the community
... She argued these working women playa dual role in the family and the workplace, they experience a sustained stress to cope in both the conditions and hence their mental well-being gets affected (Mukhopadhyay, 1997). Irrespective of the fact that they are the earning member of the family, the mental distress of women remains unacknowledged within families (Isaac & Kapur, 1980), especially Indian families do underestimate mental distress levels in women (Davar, 1999). Also, social discipline and expected role seemingly induces an anxiety in them. ...
Small businesses have their presence on every corner of the streets, and they comprise of
either services or retail operations such as medical stores, grocery stores, and provisions,
bakeries and so on. Small businesses are the second largest employment generator in the
Indian Economy next to agriculture and contribute to balanced regional development of
our nation. Since the emergence of the pandemic and the commencement of the nationwide
lockdown imposed by the government of India the businesses are facing several hurdles and
obstacles in successfully running their business thereby affecting their business performance.
This study is aimed at investigating the various hurdles and obstacles affecting the business
performance of small businesses in South India during the pandemic of covid-19. A total
sample of 200 businesses in Karnataka was being considered for this study and this study
is useful for the owners of small businesses to understand the hurdles and obstacles faced
during the pandemic and suggest suitable measures to be incorporated in order to improve
their performance.
... The tools in English were translated into the local language: Malayalam by two language experts, adopting standard procedures of translation, back translation, and cultural adaptation. SMI screening tool for use by ASHA worker: This tool is a symptom-based screening tool developed from "Symptoms in Others Questionnaire." 18,19 Symptoms in Others Questionnaire is a set of 15 questions that was developed as part of the Indian Psychiatric Survey Schedule. 18 The questionnaire is used for identifying possible cases of mental illness in the community. ...
Background
India has the second-largest population of elderly in the world. Serious mental illness (SMI) is a subset of the mental disorders that result in significant functional impairment and is usually long term. Persons with SMI face several challenges in their old age that are different from the issues faced by younger people with SMI. Understanding the problems faced by elderly individuals suffering from SMI is fundamental for planning programs to address them. The SENIOR (Support Systems Evaluation of Neuropsychiatric Illness in Old age) project is a study aimed at evaluating the problems faced in obtaining mental health care by elderly persons having SMI in the Kerala state of India.
Aim
To describe the scientific methodology of the SENIOR project.
Methods
This study employs mixed-methods cross-sectional design among a minimum sample of 768 SMI patients identified through cluster sampling from three districts, and Focus Group Discussion among mental health program officials.
Discussion
This paper presents a methodological model to assist researchers in future field epidemiological studies on mental illness. Assessing service needs and barriers to access for the most vulnerable among the mentally ill will help the policymakers make evidence-based decisions to improve their quality of life.
... A W. ti. 0 expert committee has Kapur, 1980). The reported persons were recommended that detection and management later contacted in heir own houses and assesof priority mental disorders should form an sed in detail. ...
... Most completed economic evaluations in mental health care have been carried out in the West and have been concerned with specific treatment modalities for psychoses and affective disorders, in particular the cost-effectiveness of different psychotropic medications and, more recently, various psychotherapeutic approaches to the management of these psychiatric disorders. Over the last twenty years, a small number of studies have emerged from developing countries, including consideration of the cost-effectiveness of screening for mental illness in primary care settings in Brazil and India, ( lssac and Kapur, 1980, Sen and Wilkinson, 1987, Patel et al, 1999) family therapy for schizophrenia and home versus hospital care in rural China ( Wang et al, 1994, Xiong et al, 1994) and post-discharge home visiting by nurses in South Africa ( Gillis et al, 1989). Most of these studies, however, are modest in their design, size, coverage and generalisability. ...
... Historically, the prevalence of depression in the community has been flagged off as alarmingly high, since the 1970s through the 1990s. 1 For example, Sethi et al. (1972), Chakraborty (1990Chakraborty ( , 1996, Isaac and Kapur (1980), Sharma (1987), and a host of medical writers (critically reviewed in Davar 1999a) raised an alarm about prevalence ranging from 10% up to 40%. Prevalence of depression was also reportedly high in people seeking general health care. ...
Schizophrenia is a chronic and debilitating major mental disorder which causes significant burden worldwide. Gender may significantly influence its biological features—onset, clinical symptoms, course and outcome. Gender also influences its social consequences: degree of disability, quality of life, stigma, discrimination and social outcomes such as marriage, parenting and caregiving. Gender-based disparities result in the gender gap for availability and access to treatment services and to disability benefits. We review biological and social factors which determine the outcome of schizophrenia. Social workers are well positioned to examine the critical role of gender at the intersection of the biological, psychological and social influences which determine the consequences of this illness on patients and their families. They can facilitate the formulation of gender- and culture-sensitive interventions to improve treatment outcome in both male and female patients of schizophrenia.
... Kapur & Issac (1980), identified that three major approaches have been employed as standard practise to collect information in psychiatric epidemiological research (21). The three major approaches are • Single Stage Screening Screening instruments are the most commonly used measures in psychiatry. ...
The National Mental Health Survey is a joint collaborative effort of nearly 500 professionals, comprising of researchers, state level administrators, data collection teams and others from the 12 states of India and has been coordinated and implemented by NIMHANS. The results and implications discussed in the report point to a need for a strong public health approach and a well-functioning mental health systems within larger health system.
... The Symptoms in Others Questionnaire has 15 questions that could be administered to any adult member of the household. It is designed to elicit information that might indicate the presence of serious psychiatric illness or epilepsy in either members of the family or someone in the neighborhood (Isaac & Kapur, 1980). For the purpose of this study two questions were added to the original questionnaire: The first question relates to the presence of depressed mood and the second to multiple somatic complaints, which are often regarded as surrogate marker of depression in rural communities (Srinivasan & Murthy, 1986) . ...
Background: Common mental disorders that refer to anxiety and depression syndromes are important cause of psychiatric
morbidity in primary health center. Studies evaluating outcomes of common mental disorders (CMD) from India are few.
Objectives: The aim of the present study was to examine the outcomes of the broad category of CMD and specifically major
depression in individuals resident in a rural community following naturalistic treatment with antidepressants. Methods:
Individuals with a diagnosis of CMD using a 2 stage diagnostic process were invited to seek treatment from a Primary health
center. Outcome was assessed in 144 patients diagnosed with major depression using a structured interview schedule
(SCID) at 6 months. Outcome was measured using 17-item Hamilton Depression Rating Scale (HAMD) and WHO QOL (Brev)
version. Individuals with a score of = 7 on HAMD were deemed to have incomplete remission. Results: 114 (79%) individuals
with CMD continued to be symptomatic at 6 months. Co-morbid psychiatric conditions especially anxiety was associated with
poor outcome. Individuals with higher score on HAMD had poorer quality of life as measured by WHO QOL. Treatment with
antidepressant medication did not significantly influence the outcome. Conclusion: A significant majority of individuals
diagnosed with major depression resident in a rural community had a poor outcome. However, many patients either did not
seek treatment or prematurely discontinued treatment. Implications for public health approach to the treatment of CMD are
highlighted.
... Kapur & Issac (1980), identified that three major approaches have been employed as standard practise to collect information in psychiatric epidemiological research (21). The three major approaches are • Single Stage Screening Screening instruments are the most commonly used measures in psychiatry. ...
NMHS 2015-16 Prevalence, Patterns and Outcomes.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, Mehta RY, Ram D, Shibukumar
TM, Kokane A, Lenin Singh RK, Chavan BS, Sharma P, Ramasubramanian C, Dalal PK, Saha
PK , Deuri SP, Giri AK, Kavishvar AB, Sinha VK, Thavody J, Chatterji R, Akoijam BS, Das S,
Kashyap A, Ragavan VS, Singh SK, Misra R and NMHS collaborators group. National Mental
Health Survey of India, 2015-16: Prevalence, patterns and outcomes. Bengaluru, National
Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129, 2016.
... We prepared a booklet which contained (a) a questionnaire to collect sociodemographic and household details; (b) Symptoms in Others Questionnaire (SOQ) to screen for major neuropsychiatric disorders; [4] (c) Symptom of Psychosis, a checklist based on the psychosis module of mhGAP Intervention Guide; [5] (d) General Health Questionnaire (GHQ-12) [6] to screen for CMDs which is a group of minor psychiatric illnesses such as depressive disorders, anxiety disorders, and others; (e) Everyday Abilities Scale for India (EASI) [7] to screen for functional impairment due to dementia and other cognitive impairments; and (f) CAGE questionnaire [8] to screen for problems related to alcohol abuse. ...
Background
Estimates of psychiatric morbidity in the community will help service development. Participation of trained nonspecialist health-care providers will facilitate scaling up of services in resource-limited settings.
Aims
This study aimed to estimate the prevalence of priority mental health problems in populations served by the District Mental Health Program (DMHP).
Settings and Design
This is a population-based cross-sectional survey.
Materials and Methods
We did stratified cluster sampling of households in five districts of Kerala. Trained Accredited Social Health Activists (ASHAs) identified people who had symptoms suggestive of schizophrenia or bipolar disorder. Clinicians evaluated the information collected by the ASHAs and designated individuals as probable cases of psychosis or noncases. Screening instruments such as General Health Questionnaire-12, CAGE questionnaire, and Everyday Abilities Scale for India were used for identifying common mental disorders (CMDs), clinically significant alcohol-related problems, and functional impairment.
Results
We found 12.43% of the adult population affected by mental health conditions. We found CMD as most common with a prevalence of 9%. The prevalence of psychosis was 0.71%, clinically significant alcohol-related problems was 1.46%, and dementia and other cognitive impairments was 1.26%. We found informant-based case finding to be useful in the identification of psychosis.
Conclusions
Mental health problems are common. Nonspecialist health-care providers can be trained to identify psychiatric morbidity in the community. Their participation will help in narrowing the treatment gap. Embedding operational research to DMHP will make scaling up more efficient.
... A variety of methods for evaluating the training in mental health provided to PHC personnel were developed and tested in the field [4,5,6,7]. Based on the novel experiences from its rural mental health centre, the community mental health unit at NIMHANS developed a strategy for taking mental health care to the rural areas through the existing primary health care network [8]. [12,13,14]. ...
India was one of the first in the developing world to initiate a National Mental Health Programme (NMHP) in 1982. It was conceptualized
to provide mental health care in the community as a part of general health care in a primary health care setting. The NMHP has seen
many changes in its focus and realm over the years, picking up pertinent lessons and implementing corrective changes along the way.
One of the chief turning points was the change of emphasis of the programme activities from the central/ state capital level to the district
level, by introduction of the District Mental Health Programme (DMHP). This added the needed impetus to the programme. But results
were not uniformly encouraging. A new initiative taken in October 2014 in the shape of a comprehensive Mental Health Policy by the
central government promised a change in focus on the most necessary executive actions. Currently, we are into the 12th plan period
(2012-2017), and the N/DMHP stands at the threshold of reaching its potential in considerable measure to ultimately realize the goals
set for it at the outset.
... As noted before, the process of election, the uncertainty involved therein, the shift of editorial office, the handing over of records and the acrimony that it can possibly engender, are huge stumbling blocks to a journal's forward movement. All these it can very well do without, if it seeks eventual indexing with prestigious agencies like MEDLINE (Index Medicus), the principal online bibliographic citation database of NLM's MEDLARS® system [10], and Thomson Science Citation Index SCI (earlier ISI, through the Web of Science) [11]. It is heartening to note the Journal is now indexed at quite a few indexing agencies like SCOPUS, DOAJ, Index Copernicus, Health and Wellness Research Center, Health Reference Center Academic, InfoTrac One File, Expanded Academic ASAP, Genamics JournalSeek, Ulrich's International Periodical Directory, EBSCO Publishing's Electronic Databases, Google Scholar [12]. ...
ARTICLE Practice-based research is strongly supported by the organizations of mental health consumers, governments, and insurance companies, who increasingly hold institutes accountable for both the cost-efficiency and the quality of care provided (Baker et al., 2000). Publications are a suitable source for obtaining insight into the data needed for research. The primary objectives of all mental health journals as indeed of all scientific journals is communication which is required to prevent stagnation and ultimately extinction of scientific knowledge. Scientific publications stimulate psychiatric thinking and research. Psychiatric journals are both the repository and means of dissemination of professional learning and are permanent records of facts which represent the growing horizon of psychiatric wisdom and progress (Vachha, 1964). Psychiatric publications are the mainstay for research and give ideas about techniques and procedures which are translated into day to day clinical practice. Pre-Independence Era The history of psychiatry has witnessed major evolutions to reach its present status in India. After the establishment of mental hospitals the first psychiatric unit in a general teaching hospital in India was established in 1933 at the R.G. Kar Medical College and Hospital in Calcutta. The Department of Psychiatry at the KEM Hospital, Bombay started functioning in 1947, twenty-two years after the hospital was founded (Chakarborty, 1970). Dr. Girinder Shekhar Bose founded the Indian Psychoanalytical Association in 1922 in Calcutta. A training institute of psychoanalysis was started to train young psychoanalysts. Owen Berkeley-Hill, the medical superintendent of European Mental Hospital, Ranchi, in 1929, founded the Indian Association for Mental Hygiene and he was one of the Abstract The primary objective of all mental health journals as, indeed, of all scientific journals is communication. Psychiatric journals are means of dissemination of professional learning and are permanent records of facts which represent the growing horizon of psychiatric knowledge and progress. The present review traces the legacy of research publications in the field of psychiatry in India under the aegis of Indian Psychiatric Society. The "Indian Journal of Neurology and Psychiatry" started in 1949 ushered a new era in the history of Indian psychiatry. The Indian Journal of Psychiatry started in 1958 and is completing fifty golden years of continuous enrichment in the field of psychiatry in India. The journal has witnessed different epochs and change has been a lasting pattern enabling it to leap greater heights from a glorious and wealthy past to a brighter and better tomorrow.
... [78] In addition, minority ethnic groups, including first or second-generation immigrants, have been found to be at greater risk for developing mental disorders, which has been attributed to various kinds of life insecurities and disadvantages, including racism. [79] Signs, Symptoms and Warning Signals of mental illness ...
ACKNOWLEDGMENT I owe much more than I can mention, even though I would like to add few heartfelt worlds for my esteemed teacher and elite guide Dr. M.K.Lala Associate Professor, Community Medicine Department, B.J. Medical College, Ahmedabad. Her benevolence, constant encouragement and inspiring suggestion always guided me to streamline my efforts in the right direction. Her active support and indispensible guidance, coupled with valuable advices has led to an efficient completion of my work. She has always been an exhaustive source of energy and boosted my morale. I also express my deep sense of gratitude towards my parents and husband CA Sachin Agarwal for their constant encouragement during the course of my study last but not the least my sincere gratitude to psychiatric department of civil hospital Ahmedabad, there professors, teachers and resident doctors continuously helped me in completion of my study. I also express my deep sense of gratitude towards all my senior Professors, Associate Professors & Assistant Professors for their constant encouragement during the course of my study I shall be failing in my duties if I do not express my sincere thanks to my colleagues and friends who helped me during the study period. I thank the patients attending OPD of civil hospital and their relatives and the various people in the community for their kind cooperation and assistance extended to me. It really helped me to complete this study. Though last but not the least, I am grateful to all the patients in my study whom I interviewed, without whom this would have turned out to be an exercise in vain.
... Next, the community mental health worker must identify probable cases of schizophrenia, preferably as early as possible after the onset of the disorder. The ideal model for case identifi cation is likely to be through the use of key informants (individuals who are familiar with the health status of members of the community they live in), a cost-effective method for identifying mental disorders in LAMIC [13]. Then the skilled health practitioner should make the diagnosis and initiate drug treatment. ...
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.
This is a special supplement of the Indian Journal of Psychological Medicine, the official publication of the Indian Psychiatric Society South Zone. It includes protocols of 12 single site and multi-site implementation research projects funded by the Indian Council of Medical Research. Projects address the thrust areas of the Indian National Mental Health Programme.
Depression is a ‘mood’ or ‘emotional disorder’. Underlying this naming, there are a set of universalizing colonial assumptions about women, their expressed emotions, and ‘disorders’ of the emotions. Two enlightenment ideas behind the western construal of emotions are questioned in the paper, from the gender/culture perspective: (1) emotion is (located) within the individual and (2) emotion is mental. These ideas are found in most ‘official’ therapies for depression. However, the indigenous view of emotions emphasizes the social and the embodied aspects of emotions. That is, emotion is in the body and is expressed through the body; and emotion is always in relation to the other, and often constructed with the other. The paper examines a few folk stories, and historically revered myths, including the Neeli myth from south India; the Kannagi story; and the more contemporary story of Rudali as illustrative. Women’s emotions are embodied expressions of distress; further, their object reference is to the other, often within contexts of patriarchal silencing and an extant milieu of violence. To naturalize emotions as a ‘problem’ is a colonial view, as a way of homogenizing and universalizing women’s experiences, to unify strategies of social control and control over women’s bodies.
A 45- year- old male patient presented with a complaint of black coating on surface of his tongue. He was being treated with tablet olanzapine 20 mg daily. He was not suffering from any other disease except schizophrenia. The patient was not taking any other medication. He noticed coating and black discoloration on the tongue after sixteen days of therapy.
The research literature suggests that the key elements in the comprehensive management of schizophrenia should include early detection of illness, relapse prevention, reduction of chronicity and disability, and social reintegration of patients. Delivery of such an optimal treatment would require both a wide range of mental health facilities and trained professionals with the appropriate competencies. India is a populous developing country with a limited mental health infrastructure and a marked paucity of mental health professionals. The existing facilities are geared towards providing assistance during the acute phases of the illness, and organized aftercare and psychosocial services are minimal. In addition, there is a compelling diversity in the demography, attitudes, beliefs, and needs of service seekers. This chapter highlights the challenges involved in the delivery of optimal and culturally appropriate services to people with major mental illness in India. The structural limitations of the formal mental health system suggest that a wide spectrum of community resources needs to be utilized to deliver psychosocial services to people with major mental illness. The discussion will focus on the identification and utilization of those resources that will work in synergy with the mental health system and help offset the limitations imposed by the existing infrastructure and scarcity of trained professionals.
Community psychiatry, is an important approach to the organisation of mental health care in both economically rich and in low and middle income (LAMI) countries. The development of this community psychiatry movement all over the world, is a part of series of phases of development of mental health care during the last two to three hundred years, starting from setting up special institutions for the care of the persons with mental disorders(asylums), the humane treatment of the ill persons, deinstitutionalisation, recognition of the rights of the ill persons with mental disorders. For the countries of the Region, there is not only the lack of mental health resources, there are additional burden of mental health needs arising from manmade disasters (industrial disasters, conflict, war) and natural disasters(earthquakes, tsunami). There are a number of common challenges in developing mental health care programmes in the SEA Countries, namely, (i) there is a large ‘unmet need’ for mental health care in the community; (ii) there is poor understanding of the psychological distress as requiring medical intervention in the general population; (iii) there is limited acceptance of the modern medical care for mental disorders in the general population ; (iv) there are severe limitations in the availability of mental health services (professionals and facilities) in the public health services; (v) there is poor utilisation of the available services by the ill population and their families; (vi) there are problems in recovery and reintegration of the person with mental illness and (vii) institutionalised mechanisms (policy, legislation, funding etc) for organisation of mental health care are not adequate in most of the countries. The chapter, presents the background of the development of community mental health programmes in the countries of the South Asia; the significant developments in each of the member countries; lessons learnt from the country experiences, the challenges and future directions. A striking aspect of the mental health care initiatives of the countries of the Region, is the community based and community resource based mental health services.
The terms cost-effectiveness and systems-analysis are relatively new to the Western world of health services. Both concepts originated in military operations research, made their way successfully through big industry and its corporate planning, and from there on now slowly penetrate the health sector’s management and planning.
Incidence. In many European countries, there seems to be an increase in the incidence of psychotic diseases; this appears to be related to an increase in cyclical and/or structural economic problems resulting from the growing recession in Europe, even though there is no definite evidence of the existence of a causal relationship. This leads to further economic consequences: for example, the number of cases of early retirement due to psychotic diseases is also rising, which produces further costs to society. The increase in incidence of psychotic and/or neurotic disorders, presumably caused in part by the economic development and in turn causing economic problems, provokes an analysis of the management of chronic psychotics in terms of health economics.
The Global Burden of Disease (GBD) study was conducted to provide a set of summary health measures that would be comprehensive and make available information on disease and injury, including non-fatal health outcomes. The main objective of the GBD approach was to inform global priority setting for health research and to influence international health policy and planning. One of the summary measures used was the Disability Adjusted Life Year (DALY). DALYs are a common metric for fatal and non-fatal health outcomes and are based on years of life lost because of premature death (YLL) and years of life lived with disability (YLD). Thus DALYs = YLL + YLD or Burden = Mortality + Disability. Therefore, a DALY is one lost year of healthy life. The DALY methodology provides a way to link information on disease burden to cost-effectiveness analysis. This feature would assist comparative assessments. The WHO plans to refine this framework for assessing the outcomes of interventions and their related costs.
Schizophrenia is one of the most commonly researched disorders from India. In this chapter, a brief overview of the Indian research on various aspects of schizophrenia will be presented. Notable contributions have been made in the field of epidemiology, phenomenology, course and outcomes and evaluation of various antipsychotic medications in this disorder. Research has also focused on psychosocial issues such as supernatural beliefs, aetiological models, stigma, needs, quality of life (QOL), disability, cost of care and marital issues. In recent times, data have emerged from the neuroimaging and genetic studies. Part I of this two-part chapter covers the Indian research on epidemiology, clinical features, neurobiology and psychosocial aspects of schizophrenia
Background and objective:
Economic evaluations are one of the important tools in policy making for rational allocation of resources. Given the very low public investment in the health sector in India, it is critical that resources are used wisely on interventions proven to yield best results. Hence, we undertook this study to assess the extent and quality of evidence for economic evaluation of health-care interventions and programmes in India.
Methods:
A comprehensive search was conducted to search for published full economic evaluations pertaining to India and addressing a health-related intervention or programme. PubMed, Scopus, Embase, ScienceDirect, and York CRD database and websites of important research agencies were identified to search for economic evaluations published from January 1980 to the middle of November 2014. Two researchers independently assessed the quality of the studies based on Drummond and modelling checklist.
Results:
Out of a total of 5013 articles enlisted after literature search, a total of 104 met the inclusion criteria for this systematic review. The majority of these papers were cost-effectiveness studies (64 %), led by a clinician or public-health professional (77 %), using decision analysis-based methods (59 %), published in an international journal (80 %) and addressing communicable diseases (58 %). In addition, 42 % were funded by an international funding agency or UN/bilateral aid agency, and 30 % focussed on pharmaceuticals. The average quality score of these full economic evaluations was 65.1 %. The major limitation was the inability to address uncertainties involved in modelling as only about one-third of the studies assessed modelling structural uncertainties (33 %), or ran sub-group analyses to account for heterogeneity (36.5 %) or analysed methodological uncertainty (32 %).
Conclusion:
The existing literature on economic evaluations in India is inadequate to feed into sound policy making. There is an urgent need to generate awareness within the government of how economic evaluation can inform and benefit policy making, and at the same time build capacity of health-care professionals in understanding the economic principles of health-care delivery system.
Some recent studies from Vellore, Tamil Nadu, on dementia have been published in international journals as part of international data, analysis and interpretation. They have also been published separately employing local perspectives and analysis. The different results and interpretations of these two approaches to the same data suggest the need for independent work and study of the local reality to inform national public health policies.
Early intervention in psychosis has significantly improved outcomes compared with standard treatment but it is considered as a luxury for low- and middle-income (LAMI) countries. However, a public health approach that is based on the principles of supplying all essential medication free of charge for at least the first 2 years of illness, medication being taken under supervision of a caregiver and treatment following a standardised treatment algorithm can prove a cost-effective early intervention model for LAMI countries.
As a part of designing a suitable model for mental health care delivery in rural India, a study of detection and management of priority mental disorders was carried out in 120 villages around rural mental health centre, Sakalwara in Bangalore District. During three and a half year period, the team attempted to manage 51 schizophrenics, 30 acute psychotics, 27 M. D. P. and 268 epileptics in the community with minimum number of drugs. The experiences and outcome of this attempt is presented and discussed here.
108 Psychotic and 268 epileptic patients were followed up for 3½ years as a part of an ongoing rural mental health care programme. Some of the observed situations, possible limitations and reasons for the evolved follow up pattern in this endeavour of non-institutional, family centred and community oriented treatment programme, are reported. The strategies to improve the follow up rate among the rural patients are discussed.
There is a growing consensus of opinion (WHO 1975) that in developing countries, doctors and para-medical staff of the existing health care cadres should, after a short course of problem oriented training, deliver basic mental health care. This paper describes the development and evaluation of such a training programme.
A begger's colony where a neuropsychiatric extension clinic is being run by NIMHANS, Bangalore, was selected for this study wherein 78 neuropsychiatrically ill inmates and 85 well ones were examined and diagnosed as per I.C.D.-9 and followed up on treatment. A period prevalence of 131.09/1000 serious neuropsychiatric morbidity was found with psychoses, mental retardation and epilepsy being more frequent than in general population studies. Findings in this study, point towards a need for reaching neuropsychiatric care to this section of society, and also confirm the association of certain social factors with serious morbidity.
The objective of the study was to determine the prevalence rate of priority psychiatric disorders in a rural area in Kerala and to find out the sociodemographic correlates of the morbidity. A door to door survey had been conducted by trained surveyors to identify individuals with priority psychiatric disorders. The detected cases were examined by a psychiatrist at their houses in the village itself, to confirm as to whether they were having any psychiatric disorder. Out of the 1094 households surveyed (having a population of five thousand two hundred and eighty four), seventy seven individuals were found to have priority psychiatric disorders giving a prevalence rate of 14.57 per thousand. Females in general showed increased mental morbidity. An increased prevalence rate has been observed among Scheduled Castes/Scheduled Tribes. An increased morbidity is noticed among the people belonging to the lower socioeconomic status.
To examine the naturalistic course of bipolar disorder in a rural, community-based, partially treated cohort.
All patients diagnosed with bipolar disorder during an epidemiological survey (n=34) in a rural area in India were followed longitudinally using standardized instruments, and the life-chart method used to examine their course.
Seven (26%) of the 27 patients evaluated directly had not received any treatment whatsoever. Four patients (15%) had experienced rapid-cycling at some time; patients without rapid-cycling had experienced a mean 0.22 episodes/year. Episodes of mania accounted for 72% of all episodes. None of the variables examined appeared to predict the total number of episodes experienced by individual patients, although rapid-cycling occurred significantly more often if the patients had not received any psychopharmacological treatment.
A mania-predominant course was observed in this small cohort, similar to reports from other developing countries.
This paper describes the development of a community mental health programme which is integrated with other services rendered at a primary care institution in a rural area and that addresses CMD alongside psychotic disorders and epilepsy. This initiative was a collaborative effort between the Departments of Community Medicine and Psychiatry of St. John’s Medical College, Bangalore. The programme was based at the Community Health and Training Centre at a village called Mugalur, which is 30 km from Bangalore city.
This article is the first comprehensive cultural critique of India's official community mental health policy and program. Data are based on a literature review of published papers, conference proceedings, analyses of official policy and popular media, interviews with key Indian mental health professionals, and fieldwork in Kanpur district, Uttar Pradesh (2004-2006). The authors demonstrate how three influences have shaped community psychiatry in India: a cultural asymmetry between health professionals and the wider society, psychiatry's search for both professional and social legitimacy, and WHO policies that have provided the overall direction to the development of services. Taken together, the consequences are that rural community voices have been edited out. The authors hypothesize that community psychiatry in India is a bureaucratic and culturally incongruent endeavor that increases the divide between psychiatry and local rural communities. Such a claim requires sustained ethnographic fieldwork to reveal the dynamics of the gap between community and professional experiences. The development of culturally sensitive psychiatric theory and clinical services is essential to improve the mental health of rural citizens who place their trust in India's biomedical network.
A field survey was conducted in two villages--Gambhirgachi and Paharpur--in 1972. The survey was repeated after 10 years in the former village and after 15 years in the latter one. The second survey showed very little change in the rate of total mental morbidity. The rate of prevalence of hysteria declined significantly in both villages. In Gambhirgachi the rate of hysteria dropped from 16.9 to 4.6 per 1000 in 10 years, and in Paharpur it dropped from 32.3 to 2.05 per 1000 in 15 years.
A psychiatric service was provided to the remote areas of Botswana by means of regular visits from psychiatrists and psychiatric nurses to the primary care facilities in those areas. The service was well used by the local health workers and general populations and encountered a substantial psychiatric morbidity. Studies in one region indicated that by using the primary care staff as case finders a substantial proportion of a total likely population of schizophrenic and epileptic patients could be bought into treatment. The specific conditions that enabled this service to become established are discussed.
The prevalence of psychiatric morbidity (PM) was studied among general hospital out-patients in a rural and in a semi-urban area of Kenya. There were no significant differences in the demographic features of psychiatric patients from the two areas, so the results were pooled: this gave a PM prevalence rate of 29 per cent among 388 patients. Anxiety and depression were the most frequent diagnostic categories. Alcoholism was more common in the rural than in the semi-urban area. There was no sex difference in the prevalence of PM and possible reasons for this, which is in contrast to western findings, are discussed.
Psychiatric symptoms could be readily elicited when present. Patients showing them had been ill longer than non-PM patients.
The study suggests that clinic staff not psychiatrically trained should be able to identify and treat psychiatric morbidity, even when it is presented as somatic illness.
Due to rising costs, the economic aspects of the mental health care sector are receiving increasing attention. This article scrutinizes 91 published studies in the field of mental health care, applying methodological criteria drawn from epidemiology and economics. The purpose of this study is to provide some insight into the quality of economic evaluation in the field of mental health care. The article shows that few good full economic evaluations studies have been undertaken in the domain of mental health care. One reason for this could be that the measurement of effectiveness in mental health care is complicated because of the known difficulties with the reliability of psychiatric diagnosis and the lack of consensus about the etiology and appropriate treatment for many psychiatric illnesses.
Mental health economic studies from developing countries were reviewed in the context of such studies from developed countries.
Mental health economic studies were ascertained through a systematic Medline search, chasing references at the end of papers acquired from the initial medline search and details of studies furnished by members of the WHO collaborating centre.
Only a small number of mental health economic studies from developing countries were identified. They were mainly cost-of-illness and cost-effectiveness studies.
Psychiatric disorders impose a significant burden in developing countries. It is not always possible to extrapolate findings from developed countries to developing countries. Potential avenues for future research and development are discussed.
limited healthcare budgets and a seamless demand for resources suggests that a formula for allocating resources is needed. Economic evaluation can assist in developing this formula.
mental health economic studies (cost minimisation, cost-effectiveness, cost-utility, cost-benefit and cost of illness analysis) in geriatric psychiatry from developed and developed countries were examined along with all mental health economic studies in developed countries.
there were no health economic studies in geriatric psychiatry from developing countries against a background of many such studies in developed countries. There were a greater number of health economic studies in other areas of psychiatry in developing countries. Several reasons for the paucity of such studies, the feasibility of undertaking these studies and their significance are discussed.
mental health economic studies in geriatric psychiatry in developing countries are feasible, realistic and may well have an important part to play in the allocation of resources. Also, data sets necessary for such studies are emerging from many developing countries.
India, the second most populated country of the world with a population of 1.027 billion, is a country of contrasts. It is characterized as one of the world's largest industrial nations, yet most of the negative characteristics of poor and developing countries define India too. The population is predominantly rural, and 36% of people still live below poverty line. There is a continuous migration of rural people into urban slums creating major health and economic problems. India is one of the pioneer countries in health services planning with a focus on primary health care. Improvement in the health status of the population has been one of the major thrust areas for social development programmes in the country. However, only a small percentage of the total annual budget is spent on health. Mental health is part of the general health services, and carries no separate budget. The National Mental Health Programme serves practically as the mental health policy. Recently, there was an eight-fold increase in budget allocation for the National Mental Health Programme for the Tenth Five-Year Plan (2002-2007). India is a multicultural traditional society where people visit religious and traditional healers for general and mental health related problems. However, wherever modern health services are available, people do come forward. India has a number of public policy and judicial enactments, which may impact on mental health. These have tried to address the issues of stigma attached to the mental illnesses and the rights of mentally ill people in society. A large number of epidemiological surveys done in India on mental disorders have demonstrated the prevalence of mental morbidity in rural and urban areas of the country; these rates are comparable to global rates. Although India is well placed as far as trained manpower in general health services is concerned, the mental health trained personnel are quite limited, and these are mostly based in urban areas. Considering this, development of mental health services has been linked with general health services and primary health care. Training opportunities for various kinds of mental health personnel are gradually increasing in various academic institutions in the country and recently, there has been a major initiative in the growth of private psychiatric services to fill a vacuum that the public mental health services have been slow to address. A number of non-governmental organizations have also initiated activities related to rehabilitation programmes, human rights of mentally ill people, and school mental health programmes. Despite all these efforts and progress, a lot has still to be done towards all aspects of mental health care in India in respect of training, research, and provision of clinical services to promote mental health in all sections of society.
Research and delivery of services are complementary and not alternative activities in achieving objectives of mental health programmes. If research is to contribute to the improvement of care for a set of priority conditions it should primarily aim to resolve issues underlying constraints to care provision and be the best way to remove them. Which among the topics that would satisfy this criterion will be selected will depend on secondary criteria such as feasibility, likelihood of utilisation of knowledge gained, timing of the investigations, probability of success, size of contribution to knowledge, likelihood that research will increase self-reliance in matters of research and ethical issues. Priorities for research may thus vary from country to country although the problems and priorities for service delivery may be the same. Themes in which new knowledge is likely to be useful to many settings include research on attitudes and behaviour, information spread, crosscultural issues, the process of service delivery and factors protecting health and enhancing human existence.
There is little understanding and communication in many areas between East Africa and North America. Mental health programming is no exception, although similar factors-local beliefs, political philosophy, available manpower, economic structures-largely determine program structure and services in both regions of the world. This paper describes certain program features in Tanzania, and suggests that in their simplicity they may have relevance for mental health practitioners in the Western world. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
The paper describes the development of Indian Psychiatric Survey Schedule (IPSS) which is designed to inquire about the presence of 124 psychiatric symptoms and 10 items of historical information in the general population. The symptoms as well as the items of historical information are the same as those in IPIS (Kapur et al., 1974) but because of a multi-stage procedure adopted with IPSS, the inquiry takes much less time than that for IPIS. — A preliminary interview schedule which is meant for all members of the population can be used by a nonpsychiatrist after a short period of training. The other sections in IPSS, that is detailed inquiry with the subject, detailed inquiry with an informant and observations during interview are completed when necessary by a trained psychiatrist who also gives a physical examination when somatic symptoms are reported. — The paper describes the reasons why a multi-stage procedure was designed, a pilot study which helped reach certain decisions regarding the construction of the schedule and the results of a study carried out to test the level of agreement obtained when three non-psychiatrists (after a short period of training) and a psychiatrist used the preliminary interview schedule with 40 hospital patients and 40 members of the general population.
Many psychiatrists assert that an expansion of mental health services in the developing countries is overdue. This will only take place if: (i) the tasks of mental health care are undertaken by a wide range of non-specialist health workers, including those responsible for primary health care; and (ii) services are directed initially at a very limited range of priority conditions. The method of priority selection is discussed, and the process required for translation of priority decisions into health action is exemplified by two illustrations.
When a Western-trained doctor first encounters the practice of medicine in the Third World, he cannot fail to be impressed by the apparently limitless sea of morbidity—infection, faulty sanitation, malnutrition, congenital and acquired malformations—with which a very small number of trained personnel have to cope, as best they can. In public health planning of these countries priority has to be given to arresting the killing diseases, such as malaria, tuberculosis and other deadly infections, and to the provision of basic hygiene, of pure water, and of adequate nutrition. The next priority goes to deploying preventive measures against debilitating disease, wherever such measures are known, and their application has been shown to be feasible; and finally when the expectation of life has been satisfactorily increased, attention is given to interventions which improve the quality of life.
The authors compare the bases of the treatment of mental illness by native healers and by psychiatrists. They describe the types of mental illness treated by the native healers of Bali and their methods of treatment. The authors also point out some of the lessons psychiatry can learn from shamanism.
Mental developing country:any
- T Swn
Swn'T,C. R. (1972)Mental developing country:any American Journal of Orthopsychiatry, 42,517
A rural psychiatric service in Uganda
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