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 Table of Contents    
BRIEF RESEARCH COMMUNICATION  
Year : 2011  |  Volume : 53  |  Issue : 1  |  Page : 53-56
Identifying the 'mentally disabled' in the community: How much more is to be imparted to the internees in training?


1 Department of Psychiatry, JSS Medical College Hospital, JSS University, Mysore, India
2 Department of Community Medicine, JSS Medical College Hospital, JSS University, Mysore, India

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Date of Web Publication13-Jan-2011
 

   Abstract 

Background: Studies have been conducted on the skills of physicians in general hospitals in identifying mental disorders,but there are no studies assessing the proficiency of internees in identifying mental disorders.
Aim: To confirm the diagnosis of the cases identified by 40 internees in the community as 'mentally disabled'.
Materials and Methods:
Of 15,583 people,29 were identified in the community by the internees as 'mentally disabled'.
This was followed by home visits to the houses of these 29 individuals conducted by two qualified psychiatrists and one clinical psychologist, and these cases were screened for their psychiatric status using MINI Plus.
Results: Most of the cases identified by internees as having 'mental disability' were cases of mental retardation and the others were mood and psychotic disorders and epilepsy. Cases of mental retardation and mental disorders other than those identified by the internees could also be identified while visiting the respective geographical areas.
Conclusions: There is a need to hone the skills of the medical students during the course of their training in identifying cases of mental retardation, severe as well as minor psychiatric disorders, as a part of their training. There is also a need for the use of structured scales for the same.

Keywords: Epidemiology, psychiatry, undergraduate training

How to cite this article:
Bindu A, Sathyanarayana Rao T S, Ashok N C, Prabhakar A K, Manickam L. Identifying the 'mentally disabled' in the community: How much more is to be imparted to the internees in training?. Indian J Psychiatry 2011;53:53-6

How to cite this URL:
Bindu A, Sathyanarayana Rao T S, Ashok N C, Prabhakar A K, Manickam L. Identifying the 'mentally disabled' in the community: How much more is to be imparted to the internees in training?. Indian J Psychiatry [serial online] 2011 [cited 2019 Nov 20];53:53-6. Available from: http://www.indianjpsychiatry.org/text.asp?2011/53/1/53/75562



   Introduction Top


Most of the screening in epidemiological studies is conducted by research workers from the mental health profession. There are not many epidemiological studies wherein the general physicians in a general hospital or community have collected the data. However, studies have assessed the skills of physicians in general hospitals in identifying mental illnesses. [1],[2] Singh et al. evaluated the psychiatric knowledge of 52 nonpsychiatrists, and only one doctor could give satisfactory diagnoses to the cases. [1] The deficits in the way nonpsychiatrists interview patients also hinder the identification and treatment of psychiatric disorders. [2] Mayou and Hawton opined that many cases are overlooked because the treating doctor lacks substantial skills and research techniques in gathering more evidence about the nature of the disorder. [3]

Improving the psychiatric knowledge and skills of the undergraduate students can go a long way in increasing and improving the psychiatric care across the nation. [4],[5],[6] Training undergraduates to identify psychiatric disorders will also prevent them from misdiagnosing organic conditions with psychiatric manifestations as functional in the community or in the emergency setup.

Screening of psychiatric cases in the community helps in assessing the extent of the problem and also paves way for organizing community-based mental health programs. Epidemiological studies conducted in the recent years have used newer methods of screening. Screening tools like General Health Questionnaire (GHQ), [7] and Composite International Diagnostic Interview (CIDI) [8] have been used. Surtees and Tansella recommended the use of interval GHQ [9] in situations where there are time constraints. While key informant method is used as a screening instrument, [8] Arrol et al. used a brief and easy approach for screening depression which involved asking only two questions. [10] Patients with neurosis sometimes presenting only with somatic complaints may be missed when questions based only on psychological symptoms are posed. Hence, for screening, one should be trained to interview patients based on somatic complaints, using tools like Bradford somatic inventory. [11] Clinical interview schedule-revised has also been used [12] in epidemiological studies.

In this study, we tried to confirm the diagnoses of the cases identified as 'mentally disabled' by the internees while conducting a comprehensive community survey of assessing disability in the rural and urban populations of selected areas in Mysore using MINI Plus.


   Materials and Methods Top


Phase I

The Department of Community Medicine, JSS Medical College, JSS University, conducted a comprehensive community survey of all individuals in their field action area in 2007-2008. The areas included were JSS urban health centre (5,945) in Mysore district and the rural areas of Suttur (2,821), Hadinaru (2,968), Sargur (1,216), and Nagarle (2,633) of the Nanjangud Taluk, with a total population of 15,583. The survey was carried out by the internees under the supervision of the faculty of the Department of Community Medicine. The head of each household was contacted to elicit information regarding chronic illnesses and disabilities including mental disability in each individual in the respective household. No screening tool was used for the survey. Of the urban population of 5,945, there were 3,048 men and 2,897 women and of the rural population of 9,638, there were 4,834 men and 4,804 women. Of 15,583, 29 individuals were identified in the community by the internees as 'mentally disabled,' that is, 9 men and 20 women.

Phase II

The 29 cases identified by the internees were evaluated by two qualified psychiatrists and one clinical psychologist through home visits. Visits were paid to these houses over a period of 10 days and an effort was made to trace the individuals with the help of the community health worker. The urban health centre was visited on 6 days because the houses or individuals could not be traced easily.

Tools used and procedure

Informed consent was taken from the patients or their legal guardians before conducting the interview. The cases were screened for their psychiatric status using MINI Plus, and the diagnoses confirmed. In cases of children and adults with whom interview was not possible, history was collected from the significant family member/head of the family of each house hold.


   Results Top


Of the 29 cases identified as having 'mental disability' in the phase I, only 24 could be traced, of which only 19 could be given a diagnosis and 5 were not found to have any 'mental disability' at all. Of these 19 cases, only 16 were found to have a psychiatric disorder, that is, four were cases of schizophrenia, one bipolar affective disorder, two depression, nine mental retardation, and the remaining three consisted of two cases of epilepsy and one with speech and hearing problem without any signs of mental disability [Table 1]. Also, the cases with only epilepsy, which is a neurological disorder, have been wrongly identified as having 'mental disability.' The prevalence rate as found by the internees was 1.9 per 1 000. However, the prevalence rate as confirmed through MINI Plus was only 1.02 per 1000.
Table 1: Diagnoses of the identified cases

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Twenty cases other than those identified by the internees could be identified during the visit to the community. The information was given by the community dwellers about individuals afflicted with mental disorders while enquiring about the target cases, though this was not the objective of the study. These included 11 mental retardation, two schizophrenia, four bipolar affective disorder (BPAD), one depression, one conversion disorder, and one epilepsy cases.


   Discussion Top


As per the results of the phase I, the prevalence was found to be 1.9 per 1 000. This is far less compared with what other studies have shown. The fact that more cases could be identified during the visit to the community, though it was not the objective of the study, shows that the prevalence rate could be higher as substantiated by studies on psychiatric epidemiology in India that found a prevalence ranging between 9.5 and 370 per 1,000. [13],[14] Other community studies in India have shown a prevalence of 5.8% and as estimated by the World Health Organization, 10% of the world's population suffers from mental disability. In a study conducted in rural Karnataka, Kumar et al. found the rate to be 2.3%. [15]

Thacore et al. in India showed a high prevalence of neurosis, alcohol dependence, mental retardation, and nocturnal enuresis in a community in north India and this data was obtained by doing a house to house survey for 1 year. [16] The present finding of a low prevalence could have happened due to a host of reasons like interviewing only one informant without actually interviewing the patient as opined by Suresh Bada Math et al., [13] lack of substantial interview skills, absence of a tool to screen the population, and a lack of awareness among the individuals in the community regarding mental health and mental disorders.

Another factor could be that the internees were unsure as to what comprises 'mental disability.' A search for the literature on 'disability' yields information mostly on 'mental retardation' and Indian disability evaluation and assessment scale (IDEAS); the scale to measure mental disability includes schizophrenia, bipolar disorder, dementia, and obsessive-compulsive disorder without any mention of mental retardation. [17]

Probably it reflects the undergraduate education in psychiatry too. Sethi and Trivedi have highlighted the need for revamping the psychiatric training of the undergraduate medical students. [18],[19] Though there is an increasing need for mental health care, there seems to exist an apathy among the medical fraternity toward learning and teaching psychiatry. As a result of this, there is a dearth of professionals with psychiatric skills to identify and treat mental disorders. Students do not get enough clinical exposure in psychiatry and hence lack the skills to elicit a psychiatric history or make a psychiatric diagnosis. They are not trained to use structured scales which aid in making a psychiatric diagnosis. These could have led to the underdiagnosis of the cases in this study. There definitely is a need for adequate mental health training at the undergraduate level, but it is not reflected in the medical curricula. [20] The percentage of the lecture time dedicated for psychiatry is only 15 days and Jacob suggested that a teaching period of at least 1 month is required. [21] It has also been suggested that this training is mostly required for nonpsychiatrists. [22]

Despite all this evidence of epidemiological studies and the usefulness of scales, there are certain shortcomings. Math et al. reported that the epidemiological studies in India have been inadequate in identifying panic disorders, social phobia, OCD, sexual dysfunction and substance use in the community. [13] Also, the validity of the information gathered by using scales may be questionable. Hence, the use of key informant interviews has been suggested by Charles Parry. [23]

One of the limitations of the phase 1 of the study is that the internees were not provided with a screening tool. However, there are epidemiological studies that have been conducted with only 'two questions' to screen depression in the community. [10] In addition, in the phase II, the cases were interviewed by one investigator only and hence, inter-rater reliability in making a diagnosis could not be determined. Moreover, the level of exposure of interns to psychiatry was not taken into account.


   Conclusion Top


Though there is evidence for a high prevalence of mental disorders in the community, the internees had found the prevalence to be very low. This may be a reflection of the skills of the internees in identifying the mentally disabled and also a lack of awareness regarding mental health in the community. Therefore, there is a need to hone the skills of the undergraduate students by improving undergraduate psychiatric training and teaching them to use screening tools to identify mental disorders and also improve awareness in the community.

 
   References Top

1.Singh AR, Sharma DK, Shukla TR, Banerjee KR. Psychiatric knowledge and orientation of non-psychiatrist doctors. J Acad Hosp Adm 1994;6:51-4.  Back to cited text no. 1
    
2.Scardovi A, Rucci P, Gask L, Berardi D, Leggieri G, Ceroni GB, et al. Improving psychiatric interview skills of established GPs: Evaluation of a group training course in Italy. Fam Pract 2003;20:363-9.  Back to cited text no. 2
    
3.Mayou R, Hawton K. Psychiatric disorder in the general hospital. Br J Psychiatry 1986;149:172-90.  Back to cited text no. 3
    
4.Manickam L, Sathyanarayana Rao TS. Undergraduate medical education: Psychological perspectives from India. Indian J Psychiatry 2007;49:175-8.  Back to cited text no. 4
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5.Mohandas E. Roadmap to Indian Psychiatry. Indian J Psychiatry 2009;51:173-9.  Back to cited text no. 5
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6.Reddy IR. Undergraduate psychiatry education: Present scenario in India. Indian J Psychiatry 2007;49:57-8.  Back to cited text no. 6
    
7.Vαzquez-Barquero JL, Dνez-Manrique JF, Peρa C, Quintanal RG, Labrador Lopez M. Two stage design in a community survey. Br J Psychiatry 1986;149:88-97.  Back to cited text no. 7
    
8.Shibre T, Kebede D, Alem A, Negash A, Kibreab S, Fekadu A, et al. An evaluation of two screening methods to identify cases with schizophrenia and affective disorders in a community survey in rural Ethiopia. Int J Soc Psychiatry 2002;48:200-8.   Back to cited text no. 8
    
9.Surtees PG, Tansella M. The interval general health questionnaire and its relationship with psychiatric disorder in community and general practice samples. Br J Psychiatry 1990;157:686-93.   Back to cited text no. 9
    
10.Arrol B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: Cross sectional study. BMJ 2003;327:1144-6.  Back to cited text no. 10
    
11.Mumford DB, Minhas FA, Akhtar I, Akhter S, Mubbashar MH. Stress and psychiatric disorder in urban Rawalpindi.Community survey. Br J Psychiatry 2000;177:557-62.  Back to cited text no. 11
    
12.Araya R, Rojas G, Fritsch R, Acuρa J, Lewis G. Common mental disorders in Santiago, Chile: Prevalence and socio-demographic correlates. Br J Psychiatry 2001;178:228-33.  Back to cited text no. 12
    
13.Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92.  Back to cited text no. 13
    
14.Elnagar MN, Maitra P, Rao MN. Mental health in an Indian rural community. Br J Psychiatry 1971;118:499-503.  Back to cited text no. 14
    
15.Kumar SG, Das A, Bhandary PV, Soans SJ, Harsha Kumar HN, Kotian MS. Prevalence and pattern of mental disability using Indian disability evaluation assessment scale in a rural community of Karnataka. Indian J Psychiatry 2008;50:21-3.  Back to cited text no. 15
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16.Thacore VR, Gupta SC, Suraiya M. Psychiatric morbidity in a north Indian community. Br J Psychiatry 1975;126:364-9.  Back to cited text no. 16
    
17.Indian Psychiatric Society. Indian Disability Evaluation and Assessment Scale(IDEAS) Kolkata: Indian Psychiatric Society; 2002  Back to cited text no. 17
    
18.Sethi BB. Undergraduate psychiatry. Indian J Psychiatry 1978;20:197.  Back to cited text no. 18
    
19.Trivedi JK. Importance of undergraduate psychiatric training. Indian J Psychiatry 1998;40:101-2.  Back to cited text no. 19
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20.Mitra S, Goyal S, Muliyil JP, Jacob KS. Attitudes, concerns and conduct of research among medical students. Natl Med J India 2006;19:346-7.  Back to cited text no. 20
    
21.Jacob KS. Psychiatric education for medical students. Natl Med J India 1998;11:287-9.  Back to cited text no. 21
    
22.Yamauchi T. Education of psychiatry in Japan. Psychiatry Clin Neurosci 1998;52:256-8.  Back to cited text no. 22
    
23.Charles Parry DH. A review of psychiatric epidemiology in Africa: Strategies for increasing validity when using instruments transculturally. Transcult Psychiatry 1996;33:173-88.  Back to cited text no. 23
    

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Correspondence Address:
Annigeri Bindu
Department of Psychiatry, JSS Medical College, Mysore - 570 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.75562

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