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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 35 | Issue 1
Page Nos. 1-97

Online since Wednesday, March 27, 2019

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EDITORIAL  

The concept of “Stalking” and its relevance to the existing phenomena of internet and social media p. 1
Abhijit R Rozatkar, Nitin Gupta
DOI:10.4103/ijsp.ijsp_17_19  
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PRESIDENTIAL ADDRESS Top

Social psychiatry in India: Current changes and challenges p. 4
Rajiv Gupta
DOI:10.4103/ijsp.ijsp_13_19  
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AWARD PAPER: DR. N.N. DE ORATION Top

Effect of marriage on pre-existing psychoses p. 10
Prakash B Behere
DOI:10.4103/ijsp.ijsp_9_19  
The relationship between marriage and mental illness is very complicated, and this issue commonly arises in psychotic illnesses. Psychosis is usually diagnosed at late adolescent and early adulthood. Being a disease of the age at which decision of marriage is taken, the question of whether to marry or not and whether marriage will lead to improvement or deterioration in psychoses is equally faced by patients, their family members, and treating psychiatrists. Mental disorders and problems in marriage are closely linked although there is a controversy about the sequence. In India, marriages are usually arranged by parents and are influenced by a number of factors such as astrological compatibility, caste regulation, geographic proximity, and expectations of dowry. We have worked for two decades in this area. The work summarizes as “Effect of marriage on clinical outcome of persons with bipolar affective disorder: A case–control study.” Married persons had experienced more episodes of illness and for longer duration. Males are more prone for illness than females in both groups (married and never married). Marriage did not influence the severity of illness in persons with bipolar affective disorder. The effects of marriage on women with schizophrenia are as follows: This study concluded that most of the patients and relatives were of the opinion that marriage can cure mental illness. Child birth was found to be a protective factor for decreasing separation in cases. Severity of mental illness was slightly higher in cases than comparison group. It was observed that with increasing severity of illness marital adjustment deteriorates with antagonistic interaction among members.
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AWARD PAPER: DR. A. VENKOBA RAO ORATION Top

Substance use disorders: Need for public health initiatives p. 13
Rakesh Kumar Chadda
DOI:10.4103/ijsp.ijsp_117_18  
Substance use disorders (SUDs) are associated with substantial contribution to the global burden of disease due to high prevalence, early age of onset, and chronic course. The associated physical health complications such as HIV, hepatitis B and C, and opportunist infections, stigma, myths and misconceptions, and a huge treatment gap further increase the problem. Thus, there is a strong need to take public health initiatives. Conventionally, common substances of abuse include licit substances such as tobacco and alcohol and illicit substances such as opioids, cannabis products, cocaine, barbiturates, amphetamines, and prescription drugs. The new psychoactive substances have brought a new challenge. Conventionally, the three approaches of supply reduction, demand reduction and harm reduction have been used to deal with the problem of SUDs. Preventive strategies encompassing primary, secondary, and tertiary methods need to be formally planned to meet this massive challenge. Creating awareness about the problem in the community and targeting myths and misconceptions are important to reduce the treatment gap. There is need to ensure availability and accessibility of affordable and acceptable treatment facilities, provide evidence-based treatment, and ensure ethical standards in care including coordination between health, social, and legal agencies. Relapse prevention and rehabilitation also need to be an important component of the public health policy. A well-planned public health approach involving all stakeholders is likely to be the most appropriate method to deal with the challenges imposed by the SUDs.
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AWARD PAPER: BALINT AWARD PAPER Top

Therapeutic relationship: Riding on a bumpy road and steering through to the destination p. 19
Abhishek Ghosh
DOI:10.4103/ijsp.ijsp_105_18  
Therapeutic relationship runs a dynamic course; it usually grows and intensifies with time, but there could be unforeseeable twists and disruptions. The course, to no small extent, is contributed by the therapist's dispositions and expertise on a particular theoretical orientation. Expertise is dependent on experience, level, and quality of training. Disruptions, although unwanted, give an opportunity to reflect upon the shortcomings and are an impetus for a course correction, which more often than not gives a desirable result. In this case discussion, I shall describe the highs and lows in a therapeutic relationship. After the initial euphoria, the therapist's inexperience, limited skills, and a wrong decision would contribute to significant disruption. However, the therapist's awareness of his/her limitations, a motivation to learn, and active help from mentors and colleagues would provide momentum in the second half of the therapy, which finally would see the daylight of success.
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AWARD PAPER: DR. GC BORAL AWARD PAPER Top

Comparative survey of factors associated with illness-related knowledge among patients with severe mental illness and their caregivers p. 24
Snehil Gupta, Mamta Sood, Rohit Verma, Jawahar Singh
DOI:10.4103/ijsp.ijsp_112_18  
Background: Knowledge about the illness and treatment is important for treatment adherence and positive outcomes in patients with severe mental illnesses (SMIs) and their caregivers. The current study aimed at comparing the knowledge of the patients with SMI and their caregivers, and its relationship with their sociodemographic characteristics. Methodology: A cross-sectional, observational study conducted in the outpatient department of a tertiary care general hospital and comprised 50 dyads of patients with SMIs and their caregivers. Information was collected by a semi-structured questionnaire. Comparison of knowledge between groups was performed using the Chi-square test, and the relationship of knowledge with their sociodemographic variables was analyzed using logistic regression test. Results: There was a lack of knowledge among participating dyads for most of the illness- and treatment-related variables. A significant difference was observed between the two groups in regard to their knowledge about the name of the illness, how medical comorbidity and comorbid substance use affect psychiatric illness, brand name of the medicine, adverse effect, duration of treatment, role of investigation in diagnosis and treatment, and psychosocial rehabilitation (P < 0.001). The difference in knowledge was also observed regarding the formulation of medicine other than tablets and mechanism of its action (P < 0.05). Dyads with higher socioeconomic status had more knowledge about some but not all aspects of their illness. Conclusion: The patients and their caregivers lacked knowledge about many important illnesses-related variables. It is important to psychoeducate in routine clinical practice.
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AWARD PAPER: DR. JK TRIVEDI AWARD PAPER Top

Relationship between illness disability in patients with first-episode schizophrenia with caregivers' perception of their needs p. 32
Ragul Ganesh, Rohit Verma, Rachna Bhargava, Mamta Sood
DOI:10.4103/ijsp.ijsp_111_18  
Introduction: The humanistic burden of schizophrenia is levied mostly upon the families in India which act as the primary source of caregiving. Studies have found that symptomatic patients with schizophrenia suffer from significant disability compared to those patients with minimal symptoms. Studies have reported positive correlation between patient's disability and higher number of needs perceived by caregivers of schizophrenia. There has been no evaluation of this aspect in first-episode schizophrenia (FES). Objective: The objective of this study was to evaluate the disability in patients with FES and find the relationship with the caregivers' perception of their needs. Methodology: This cross-sectional study included symptomatic patients with FES (Group 1; n = 30) along with their caregivers and patients with FES having minimal or no symptoms (Group 2; n = 30) along with their caregivers. The assessment was done using the World Health Organization Disability Assessment Schedule 2.0 for patients and Camberwell Assessment of Need-Short Appraisal Schedule for caregivers. The correlation was done among the level of disability in patients, patients' needs as perceived by their caregivers, sociodemographic, and clinical variables. Multiple regression analysis was done with needs as the dependent variable and other variables as independent predictors. Results: Among the patients with FES, Group 1 had higher disability scores than the Group 2 (t = 23.22, P < 0.01). Total needs of the patients as perceived by their caregivers were similar in both the groups. The unmet needs were more for Group 1 as compared to Group 2 (t = 16.45, P < 0.01). The former had more met needs compared to the latter (t = −13.23, P < 0.01). Disability in patients was positively correlated to illness duration (r = 0.65), unmet needs (r = 0.96), and total needs (r = 0.71). Sociodemographic parameters are not related to illness-related disability or caregivers' perception of the needs. Patients' disability, alogia, and asociality were the significant positive predictors of the unmet needs as perceived by caregivers in Group 1. Conclusion: Symptomatic patients with FES have more disability and more unmet patients' needs as perceived by their caregivers as compared to FES with minimal or no symptoms.
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AWARD PAPER: DR. ANIL MALHOTRA AWARD PAPER Top

Psychometric properties of the Hindi-translated version of the “Assessment of Recovery Capital” scale at a tertiary level de-addiction center in North India p. 40
Aniruddha Basu, Surendra Kumar Mattoo, Debasish Basu, BN Subodh, Suresh Kumar Sharma, Fazl E Roub
DOI:10.4103/ijsp.ijsp_107_18  
Background/Objectives: The concept of “recovery capital” with regard to substance use draws upon the personal, social, cultural, and human resources in an individual to undergo recovery. However, lack of any structured instrument for its assessment in the local context necessitated the translation of the English self-assessment version of “Assessment of Recovery Capital” (ARC) scale to Hindi and the study of its psychometric properties. Methodology: In a cross-sectional study at a tertiary-level de-addiction center in Northwestern India, in the initial phase, forward translation to Hindi followed by expert panel back-translation, pretesting and cognitive interviewing were done. Thereafter, it was administered on 200 respondents of whom 100 were active alcohol-dependent or other illicit/pharmaceutical opioid-dependent users and another 100 dependent respondents were abstinent from such substances for the last 1 year. Results: Cognitive interviewing determined its face validity, whereas principal component analysis established a single-factor structure. It was shown to have good internal consistency (Cronbach's alpha = 0.86) and test-retest reliability (rho = 0.93, P < 0.001). Concurrent validity was established by comparing with the World Health Organization quality of life-BREF (P < 0.01), whereas predictive validity by significant area under the curve value of 82% and optimum cutoff of 41.5 (sensitivity: 81%, specificity: 71%) in the receiver operator characteristic curve. Divergent validity was established by lack of any significant positive correlation with the Addiction Severity Index (version 5.0). Conclusion: Hindi ARC has acceptable psychometric properties as a monitoring instrument for “recovery-oriented” de-addiction services. However, this needs to be studied in different settings with different substances longitudinally for its final validation.
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REVIEW ARTICLE Top

Trajectory of perinatal mental health in India p. 47
GT Harsha, Mithun Sadashiva Acharya
DOI:10.4103/ijsp.ijsp_30_18  
The global burden of psychiatric disorders in women is on the rise, especially in the perinatal period. Despite this, the recognition of the need and delivery of health care in women of reproductive age group is scarce and still met by unscientific treatment modalities. Such a scenario is luring in India as well. We have focused on discussing the impact of culture on the treatment practices, different challenges faced, nosological status, and management principles of different perinatal psychiatric disorders. We mainly employed the Google Scholar search engine to look into articles of all sorts (review articles, case reports, expert opinions, newspaper extracts, and Indian government websites) and reviewed them. We also acknowledged the information extracted from these articles which were highly valuable and enlightening. The perspective of the health-care delivery in the perinatal group of population has been changing over the years, but still there is lot to change. A holistic, scientific, evidence-based approach is a definite need toward attaining this goal.
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COMMENTARY Top

Perinatal (Mother-infant) psychiatry in India: Now is the right time to talk p. 55
Balaji Bharadwaj
DOI:10.4103/ijsp.ijsp_52_18  
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ORIGINAL ARTICLES Top

Study of depression, anxiety and stress among Class IV workers in a medical college in Delhi p. 57
Prachie Garg, Rajesh Kumar
DOI:10.4103/ijsp.ijsp_85_17  
Context: India contributes significantly to the global burden of mental illnesses in the world. Class-IV workers tend to have poor socioeconomic status, low levels of education, and long erratic working shifts. However, there is a lack of studies to assess their mental health and its impact on quality of life (QOL), especially in the Indian context. Aims: The objectives of the current study were to (i) assess the levels of depression, anxiety, and stress among Class-IV workers in a medical college of Delhi, (ii) study the association of sociodemographic variables with depression, anxiety, and stress levels, and (iii) assess the impact of these psychometric variables on overall health and QOL. Materials and Methods: A cross-sectional study was conducted in a medical college of Delhi where Class-IV workers were interviewed using a sociodemographic questionnaire and psychometric tools such as DASS-21 and Short Form Survey-12 (v2) (QualityMetric). Statistical analysis included prevalence data, multivariate binary logistic regression, and multiple linear regression. Results and Conclusions: The prevalence of depression, anxiety, and stress in Class-IV workers was found to be 17%, 15%, and 6%, respectively. The results showed that workers belonging to upper middle socioeconomic class were less likely to have depression than upper lower class (odds ratio [OR] = 0.048, 95% confidence interval [CI] = 0.003–0.866). Workers educated till primary level were more likely to have anxiety than those educated till high school and beyond (OR = 8.736, CI = 1.28–59.64). Those commuting longer distances from home to workplace daily were less likely to have depression (OR = 0.017, CI = 0.00–0.735) and anxiety (OR = 0.059, CI = 0.004–0.851). High levels of depression, anxiety, and stress had a negative impact on the overall QOL as well (P = 0.001).
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A community-based study of postpartum depression in rural Southern India p. 64
Vanishree Shriraam, Pankaj Badamilal Shah, M Anitha Rani, B. W. C. Sathiyasekaran
DOI:10.4103/ijsp.ijsp_13_18  
Background: Depression is the most common complication postpartum affecting 10%–15% of women, contributing greatly to maternal mortality and morbidity, but the care availed is very low among the women who suffer. Objective: The aim is to study the prevalence of postpartum depression among recently delivered women in a rural population and the health care utilization pattern for the condition among women. Methodology: This was conducted as a population-based cross-sectional study in a rural population served by primary health center. All women in the study area who had a pregnancy outcome during the past 6 months and have completed 42 days since their last delivery were included in the study. The data on postpartum depression were collected using the Edinburgh Postnatal Depression Scale (EPDS). Results: There were 365 postpartum women in the study area who participated in the study. Mean age of the study participants was 24.5 years. The deliveries were Institutional in 97.8% of women. The prevalence of depression among the study women (an EPDS score of 10 and above) was 11%. Among women with depression, a history of depression before the last delivery was given by 42.5% of women. Only 7.5% of women had sought some form of health care for their problem. Conclusion: The study shows that the prevalence of depression among postpartum women is quite high and the health seeking for depression is very low. Health professionals and workers have to be trained to raise awareness, detect, and treat depression among postpartum women promptly.
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Awareness and attitude toward mental illness among a rural population in Kolar p. 69
C Ruth Sneha, Mohan M Reddy, Mona Nongmeikapam, Jagadish S Narayana
DOI:10.4103/ijsp.ijsp_23_18  
Background: There are few studies dealing with the diversity in people's knowledge and attitude toward mental health problems. Materials and Methods: This is a descriptive cross-sectional study, conducted in Sri RL Jalappa Hospital and Research Centre, Tamaka, Kolar. The relatives of all patients who visited the hospital served as the study population. A total of 300 consecutive individuals fulfilling the inclusion criteria were chosen for the study. The participants were interviewed using the public perceptions of mental illness questionnaire after obtaining a written informed consent. Results: Majority (39%) of the participants agreed that mental illness is caused by brain disease. On the other hand, one-fifth thought mental illness was God's punishment. About 22% thought that people with mental health problems are largely to blame for their own condition and one-third felt that someone with a mental illness was usually dangerous. The study also identified the magnitude of the stigma attached to mental illness. Almost half (46%) of the participants said they would not want people to know about it if they had a mental illness. Less than one-fifth thought someone could recover from mental illness and only 11% was aware that mental health services were available in the community. Conclusion: The present study concludes that the understanding of the nature of mental illness, its implications for social integration and management remains poor among the general public. Hence, the need for well-coordinated public education, mental health awareness programs and increased accessibility of effective mental health services.
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Challenges faced by state and society in providing care to homeless mentally Ill Patients: Know the unknown project p. 75
Guru S Gowda, G Gopika, Tarasingh N Sanjay, Channaveerachari Naveen Kumar, Narayana Manjunatha, Ravi Yadav, Dwarakanath Srinivas, Rose Dawn Bharath, Suresh Bada Math
DOI:10.4103/ijsp.ijsp_122_17  
Background: Homeless mentally ill (HMI) patients pose a major problem in our society. There are no specific, focused studies to understand the complex needs and the challenges faced by state and society in providing care of HMI patients in India. Objectives: This study was planned to understand the challenges faced by state and society in providing care to HMI. Materials and Methods: We performed a retrospective chart review of “HMI” patients from January 1, 2002, to December 31, 2015, who were admitted to the Department of Psychiatry at National Institute of Mental Health and Neuro Sciences, Bengaluru, India. Pathway to care and reintegration outcome characteristics were analyzed using descriptive statistics. Results: In our study, among 78 HMI patients admitted, police 32 (41%), public 32 (41%), and nongovernmental organizations (NGOs) 14 (18%) were the first contacts who found HMI patients. In the 15 weeks of mean duration of inpatient care, 40 (51.3%) were reintegrated into the family through a multidisciplinary approach. However public, NGO, Clinicians had multiple challenges in admission, treatment services, rehabilitation, and aftercare of HMI patients. Conclusion: Holistic care and services for HMI patients are challenging and have multiple hurdles with the existing infrastructure in India. Better care might be possible with collaborative, multidisciplinary approach with NGOs, Rehabilitation centers, local police, judiciary, and psychiatric facilities. Mental Health Care Act 2017 has addressed above few challenges making admission procedure simpler, administering free treatment, involving police officers in the identification of HMI, admission to hospital, tracing HMI, and reintegration with the family.
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Cognitive behavioral therapy and functional impairment in obsessive–Compulsive disorder p. 80
Laxmi Narayan Rathore, Jai Prakash
DOI:10.4103/ijsp.ijsp_97_17  
Background: Obsessive–compulsive disorder (OCD) is characterized by the presence of obsessions and compulsions and has a lifetime prevalence of around 2%–3%. Increase in symptoms severity in OCD is associated with noticeable impairment in daily psychosocial functioning of the patient, that further add-on to the stress level of the individual and increases burden on the family and society. Therefore, effective and timely management is required. Literature favors cognitive behavioral therapy (CBT) intervention in managing symptoms severity in OCD. The present study attempts to look its role on functional impairment of such patients. Methods: Pre- and post-intervention with a control group design were made to conduct this study involving 20 patients with OCD. Patients were equally divided in two groups where one group was given intervention with CBT sessions for 10 weeks. Pre- and post-intervention assessment was done using Yale–Brown Obsessive–Compulsive Scale (YBOCS) and dysfunctional analysis questionnaire (DAQ) and results were compared. Results: Obtained data indicate significant decrease in composite score on YBOCS and significant increase in composite and domain-wise scores for DAQ assessment at postintervention assessment, in the group which has been given intervention with CBT as compared to the other group. Conclusion: Finding reveals that CBT has an impact in improving the functional ability along with remission of primary obsessive–compulsive symptoms in patients with OCD.
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Assessment of caregiver burden and their quality of life at a tertiary care center: A cross-sectional study p. 88
Joan Choondal Puzhakkal, Roy Abraham Kallivayalil, Sanu Sudhakar
DOI:10.4103/ijsp.ijsp_119_17  
Background: Caregivers (CGs) of persons with psychiatric illness have different levels of burden and quality of life. Objectives: The objectives of the study were to assess the levels of CG burden, to determine the correlates of CG's burden, and also to examine perceived burden and its influence on the quality of life. Settings and Design: It was a comparative cross-sectional study conducted at a tertiary care center. A total of eighty CGs were assessed within 1-month period by consecutive sampling. Methodology: CGs of patients from four different groups, twenty participants each from schizophrenia, bipolar affective disorder, alcohol use disorders, and depressive disorders, were assessed using the Burden Assessment Schedule and World Health Organization Quality of Life-BREF scale. Statistical Analysis: The data were analyzed using Statistical Package for the Social Sciences software version 20. Results: CGs of persons with schizophrenia were found to have the highest and depressive disorders with least burden. Burden significantly increases for CGs who are below poverty line, when they get physical illness during caregiving process, and for primary CGs. CG burden increases with severity of illness except in depressive disorders. Quality-of-life domains were significantly different among all groups. There was a significant negative correlation between CG burden and quality of life in all the four groups. Conclusion: CG's quality of life is adversely affected by the process of caregiving. By addressing the level of burden and providing appropriate remedial measures, we could improve the quality of life of CGs, thus facilitating the prognosis of the diseased.
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BRIEF COMMUNICATION Top

Behavioral addiction as a comorbidity to pathological gambling: Implication for screening and intervention in health setting p. 93
Manoj Kumar Sharma, Girish N Rao, Vivek Benegal, K Thennarasu, Divya Thomas
DOI:10.4103/ijsp.ijsp_109_17  
Background: Gambling has been portrayed in many anecdotes in the culture of India as an addiction associated with psychosocial dysfunctions. The present study assessed pathological gambling and other behavioral addictions as a comorbid condition in an urban Indian community. Materials and Methods: A total of 3250 individuals were approached to report on gambling behavior and other behavioral addictions using a door-to-door survey approach and 2755 participated in the study. The Lie–Bet Tool for gambling, Behavioral Addiction Screening Checklist, and Internet Addiction Test were administered. Results: Of those surveyed in the age group of 18–50 years, 1.2% reported pathological gambling along with the presence of eating, mobile phone, or television addiction. Only 0.3% of the participants reported the need to change gambling behaviors. Conclusions: These findings have implications for screening and intervention for the management of behavioral addictions that are comorbid with gambling.
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