Factors affecting adherence/compliance among patients diagnosed with unipolar depression in a General Hospital in Kolkata
Dr Sohini Banerjee, Dr Sayanti Ghosh, Dr Raviprasad Verma
Background
Non-adherence with psychotropic medication is a common phenomenon globally. However, adherence to anti-depressant medication in subjects diagnosed as unipolar depression requires methodical study. Limited evidence in this regard is available from India. This study aimed to assess the correlation of non-adherence to prescribed treatment among patients suffering from unipolar depression.
Method
A cross-sectional study was conducted in the Psychiatric Out Patient department (OPD) of R G Kar Medical College and Hospital in Kolkata. The Morisky Medication Adherence Scale (MMAS) was used and a questionnaire was designed by the principal investigator and was administered to the patients to explore correlation of non-adherence.
Results
A total of 239 { 63 men (26.4%), 176 women (73.6%) } patients with unipolar depression were interviewed of whom 79(33.1%) were adherent and the remaining 160(66.9%) non-adherent and the difference between two groups were found to be significant (Fisher’s Exact <0.000). Women were found to be nearly three times at a higher risk of being non-adherent compared to men(OR 2.7; 95% CI 1.0-7.1). The non-adherent group was significantly more likely to consume extra pills than the recommended numbers ( OR 2.8; 95% CI 1.1-7.3) and considerably lower internal locus of control ( OR 4.5; 95% CI 2.4-8.3)
Conclusion
Adherence to prescribed treatment in an out-patient clinical setting was problem among patients with unipolar depression. Interventions focusing on individuals with the above mentioned attributes and intersectional systems-oriented approach to improve adherence is needed for effective strategies in India and setting elsewhere where non-adherence to depression therapy is an important public health problem.
A correlative study of oral health status and hand writing analysis of psychiatric patients
Abarna Sen, Dr D G Mukherjee, Dr S Mukherjee, Dr R N Maity
Abstract
The psychiatric patients are reported to have poor oral health. Hand writing analysis or graphology is used as a medical diagnostic tool which reflects the mental conditions of these subjects in their writing scripts. The oral health of 50 psychiatric in-patients in a psychiatric department of a teaching medical college was examined and handwriting samples of these subjects were taken on a blank white page. The relationship between oral health status and the subjects’ mental health, as reflected by handwriting analysis was examined and analyzed in detail.. Facial dysmorphism, high caries status, periodontal problems were among the oral health measures which showed proportional relationship with lack of organization, lack of internal baseline and poor self-image in their handwriting analysis.
We found that 44 out of 50 patients were having high periodontal problems than that of healthy periodontal status (Z=5.37, p<0.001). The DMF index suggests that although decayed teeth were 60%, missing (10%) and filled (2%) teeth constitute a small percentage.
Most of the handwriting shows lack of organization (86%), lack of internal baseline(88%), lack of planning abilities (poor margin 76%) and poor self-image (76%).
Correlation analysis of data on total number of patients were performed and correlation co-efficient was found to be highly significant (Y=0.9959,t=26.85,df=6,p<0.001).
In conclusion, more attention is required to overcome the problem of mentally disordered patients and strict habit regimen monitoring should be implemented. However, more such studies are required to arrive at more definite conclusion.
‘The effect of maternal aggression, adjustment on the extent of attention-deficit hyperactivity disorder among school going ADHD children.
Dr Saswati Nath
Place of study: child guidance clinic of the Department of Psychiatry of this hospital.
Methods: All mothers who attended the clinic with her school going child with complains of poor academic performance, lack of attention and impulsivity were screened for ADHD using Child Symptom Inventory. 24 children were selected. Confirmed diagnosis was made according to DSM IV criteria. Out of 24 children, 14 children were diagnosed with ADHD. Conner’s Abbreviated Parent Rating Scale for ADHD was used to assess the severity of ADHD and Vanderbilt ADHD Diagnostic Parent Rating Scale was administered to determine the comorbidities among school going urban ADHD children. Aggression Scale (A-Scale) and Indian Adaptation of Bell’s Adjustment Inventory was used to rate the levels of aggression and adjustment of mothers having ADHD children. Mean & Standard Deviation (SD) were administered to determine the arithmetic average of a distribution of scores & the average deviation between the individual scores in the distribution and the mean for the distribution. The Chi-Square test is performed to determine the statistical significance between scores of maternal aggression and adjustment of mothers having low & high degree of ADHD children.
After explaining the purpose and method of the study to all the participants, consent was taken from each of them. All mothers (subjects) of the selected children were administered with Conner’s Abbreviated Parent rating Scale. Out of 24 children, 14 children were diagnosed with ADHD. Then those 14 mothers were given Vanderbilt ADHD Parent Rating Scale to determine their children’s subtype and co-morbidity, if any. Subjects were administered with Aggression Scale (A-Scale) and Indian Adaptation of Bell’s Adjustment Inventory. The data collection procedure continued for almost 1 year (May 2010- April 2011). Then the collected data were scored and statistically interpreted.
Progress of work:
Data collection, Statistical Analysis, Writing - Complete
Sample Size: 14
Children with High ADHD= 8
Children with Low ADHD= 6
Results: No significant association was found between mother’s level of aggression or adjustment capacity with child’s ADHD symptom. It is reestablished that ADHD is a purely organic illness resulting from brain damage which is not affected by maternal behavioral factors. However, result showed significant positive correlation between maternal aggression and child’s comorbidity. The study found that there was no statistically significant difference in the level of aggression and adjustment scores of mothers having high & low degree of ADHD children. However, due to small sample size and time constraint we were not able to study interaction effect.
The paper is now ready for submission.
A study on effect of antenatal depression on birth weight of babies
Dr Anish Kumar Dawn , Post Graduate Trainee , Dr D G Mukherjee,
Objective: To study the antenatal mothers at their second trimester of pregnancy, attending antenatal clinic of Department of Gynaecology & Obstetrics, in a teaching institute ,Kolkata in respect to socio-demographic characteristics ,the nature and extent of depressive disorders, the relationship between antenatal depression and birth weight of babies at term of the above patients and the difference in outcome among (a)conventional treatment with pharmacological interventions and (b)conventional treatment with psychological interventions in two groups of mothers suffering from antenatal depression, (c) normal antenatal mothers.
Method: For 2 consecutive months 1265 Subjects were screened with Self reporting questionnaire for evaluation of psychiatric morbidity. Subjects (963) scored below psychiatric morbidity (SRQ SCORE <7) were treated as normal. Among them who fulfilled the inclusion and exclusion criteria were included as control group. Those (302) scored above cut up point (SRQ SCORE 7or more) were considered as having psychiatric morbidity and a semi structured interview proforma was used for psychiatric examination and Mental Status Examination to qualify for a syndromal diagnosis (ICD-10).205 Cases diagnosed as Depressive disorder and who fulfilled the inclusion and exclusion criteria were included as subjects(168) of present study as experimental group and cases(97) having other Psychiatric morbidity were excluded from the present study. All sample subjects(168) of the experimental group were randomly (by generating random number by computer) assigned to either of the two subgroups (84 subjects in each sub group)-A. Depressive disorders provided pharmacological treatment with antidepressant (Sertraline) and routine antenatal obstetrical care. B. Depressive disorders provided Psychological counselling and routine antenatal obstetrical care.
Results: Extent of ante-natal depression during the second trimester of pregnancy was 16.21% of the total sample size of all ante-natal mothers attending at the second trimester of pregnancy. Among the socio-economic variables, significant co-relation was seen in three areas, namely, education of the patient ( p<0.001), education of the head of the family ( p<0.004), occupation of the head of the family (p<0.037) in between the comparison group and the experimental group, i.e., depression in pregnancy was associated significantly with lower education of the patient as-well-as the head of the family & hierarchically lower occupational status. The average age of depressed group are significantly lower than that of non depressed group, There was no significant difference regarding birth-weight between the pharmacological group and the control group. But birth weight of the counseling group was found to be significantly lower than that of the control group. Given that severity of symptoms of depression as per BDI score was significantly more reduced in the pharmacological group than the counseling group, pharmacotherapy of depression may have been considered as a predictor of birth-outcome, as demonstrated in the study.
Summary and Conclusion :As previously reported we also found that depression is common during pregnancy and that lower level of education of the patient as well as that of the head of the family, lower status of the occupation of the head of the family are associated with an increased prevalence of antenatal depression. Maternal depression during pregnancy predicts Low Birth Weight. Interventions aimed at maternal depression may help improve infant outcomes specially pharmacotherapy than psychotherapy. Future works should include diagnostic assessments for depression when examining risk factors and should attempt to use consistent screening tools along with structured Psychiatric interview for the diagnosis of the depressive disorders. Lastly, the creation of a mental health team in antenatal services to treat psychiatric disorders during and after pregnancy might prevent or ameliorate both birth outcomes as well maternal morbidity.
Psychopathology of the children suffering from chronic illnesses due to thalassemia and nephritic syndrome
Dr D G Mukherjee, Dr Pradip Kumar Paria
Objective: To evaluate and compare psychopathology of the children suffering from chronic illnesses due to thalassemia and nephritic syndrome
Methods:A descriptive observational study of cross-sectional design was undertaken amongst children suffering from chronic illnesses due to thalassemia and nephritic syndrome, each comprising 30 randomly selected cases within the age range of 5-14 years. Children with illnesses of less than 12 months duration and having mental retardation or any other medical or surgical illness were excluded. CPMS ( Childhood Psychopathology Measurement Schedule ) was used to measure the behavioral profile of the children. Thorough clinical examination was done in each case to supplement the diagnosis according to ICD-10 classification
Results
Life-style changes were seen in 73% of thalassemia cases and 36% of nephritic syndrome patients. Parents of thalassemia patients felt more stress (83%) than those of nephritic syndrome (53%). The study revealed that 60% of thalassemics were poor academic achiever compared to 30% amongst nephrotics. Behavioral changes were seen 73.3% of the thalassemia compared to 43.3% of the nephritic syndrome patients. The common observed behavioral changes were conduct disorder, mixed disorder of conduct and emotion (like depression), anxiety disorder and other childhood emotional disorder. No association was found between socio-demographic variables and psychiatric morbidities except males were affected more frequently in both the study population.
Conclusions
This study emphasizes the importance of integrating a multidimensional psychosocial battery in the regular follow-up and clinical assessment of children with chronic illnesses like thalassemia major and nephritic syndrome.
Internship training in Psychiatry: Need for a review
Dr D. G. Mukherjee
Internship training in psychiatry provides the initial exposure to undergraduate psychiatry education considering both challenges and prospective opportunities for the medical student. However, a number of issues, including structure of training, faculty development and providing quality training and education remain yet to be resolved. Research evidences show that interests and attitude amongst medical students with respect to the discipline of Psychiatry has been found to be low. Lancet Editorial commented the best teaching is unlikely to prevail against poor working condition, a bad professional image and the frustrations of dealing with society’s misfits and people who rarely appeared cured, is less rewarding. Exposure to training in psychiatry however have been found to have an influence on the change in attitude towards mental illness, though it did not influence the choice to the career of medical undergraduate students. However, recently there has been a shift in favourable direction in the general attitude to Psychiatry among medical students, considering Psychiatry specialty as challenging and scientific.
140 medical students undergoing internship training in Psychiatry were assessed following experimental training in the Department of Psychiatry. Multi-disciplinary learning was emphasized on learning of effective communication skills, allowing preparation for addressing and treating mental disorders.
Summative assessments were done at the end of the two week training to receive feedback from the students regarding their experience during their posting in Psychiatry. Formative assessments were also done after four weeks separately to assess the knowledge, skills and expertise to treat and manage mental disorders. The findings of the study will be discussed in detail, considering the various issues related to improvement of structure of internship training in Psychiatry.
Diagnostic validity of hyperkinetic disorder
Dr Saikat Mitra, Post-Graduate Trainee
Dr D. G. Mukherjee, Dr Saswati Nath,
Objectives
Despite considerable research, there is continuing controversy regarding the nature and validity of the syndrome termed Attention Deficit Hyperactivity Disorder (ADHD) according to DSM IV and Hyperkinetic disorder (HKD) according to ICD 10. Hyperkinetic disorder is controversial in part because most children are diagnosed and treated based on decisions made by their parents and clinicians with teachers being the primary source of diagnostic information. Many aspects of hyperkinetic syndrome have proved to be very contentious- theoretically, conceptually and clinically. The clear picture of natural history of hyperkinesis is obscure. Some argue that the symptoms may simply describe the exuberant behavior of normal children. Others accept that it is a valid disorder, but contend the weakness in the current diagnostic criteria, that causes some children to be diagnosed inappropriately. Considering such conflicting reports and discrepancies, there is a need for specific scientific enquiry to ascertain the diagnostic validity of the controversial Hyperkinetic syndrome. Considering its worldwide prevalence as estimated to be 5.2 per cent , we need to critically examine the criterion definition of the disorder under question.
Aims
To assess the diagnostic validity of hyperkinetic disorders and whether Hyperkinetic disorders and its subtypes, diagnosed according to DCR 10 criteria, have concurrent, discriminant, antecedent and predictive validity.
Methods
Children attending Child Guidance Clinic of a tertiary centre in Kolkata, aged 5-12 years of IQ more than 50 who would fulfill the inclusion and exclusion criteria and diagnosed as having hyperkinetic disorders as per DCR 10 after proper screening by CSI, were selected. Any neurological deficit, sensory problems or co-morbid psychiatric illness were excluded. 50 children diagnosed as Disturbance of activity and attention (F90.0) and 50 children diagnosed as hyperkinetic conduct disorder (F90.1) as per DCR 10 made the sample. They were first screened with Child Symptom Inventory (CSI-4): Parent version screening tool by the investigator and then assessed by DCR 10 by a separate clinician for proper diagnosis. Socio-demographic, birth and developmental parameters, family history and treatment methods were recorded. Appropriate statistical method was applied thereafter for data analysis.
Results
Principal Component Analysis (PCA) was performed over the CSI-4 scores. Three distinct components arose out of it in the unrotated component matrix. One component consisted of ‘hyperactivity-impulsivity’ items with ‘oppositional and conduct’ items (component 1); the second consists of only ‘inattention’ items( component 2) and third being one ‘inattention-hyperactivity-impulsivity’ items ( one item from each cluster, may be called combined- component 4). In terms of antecedent factors, the data showed significant difference between the two groups in certain socio-demographic variables. There is significant sex difference with male preponderance in the HCD group. The children with hyperkinetic disorder were found to be born significantly more with prematurity and subsequent instrumental delivery with 100% institutional birth. Family discord was found to be significantly more in the HCD group. There was significant improvement with treatment in both of the groups.
Conclusion
The hyperkinetic syndrome as in DCR-10 leaves a mark of immense possibility of becoming a valid medical diagnostic entity. Medical diagnosis requires not only uniformity in symptom-profile, family history, treatment response and course and outcome, but also requires an etiological basis to understand the etiopathogenesis of a disorder. Preliminary observations from this study, directs for wider search for the etiological factors which might be implicated in this group of clinical symptom-based entity.
Multicentric study on assessment of health care needs of patients with severe mental illness
Dr D G Mukherjee
Nodal centre: PGIMER, Chandigarh
Study centre: R G Kar Medical College
Outcome measures in Psychiatry, have incorporated not only clinical symptoms, but a combination of measures of physical health, mental health, social functioning, role functioning, general perception of health and well-being, cognitive capacity and patient satisfaction. These outcome measures include Quality of Life, level of disability and level of functioning. However, these do not provide much information about how the dysfunction or lack of satisfaction can be removed. Over the years, the concepts of ‘needs’ has been evaluated as a measure of outcome, so that information can be gathered from the patients, carers and physicians with respect to what can be done to improve the overall outcome of the patients. Further the concept of ‘need’ has been clarified to understand the mismatch between demands of the patients and the carers and the services provided. From the health care perspective, ‘need’ is considered to be present when the subject’s level of functioning falls below some minimum specified level (i.e., there is distress from symptoms or disablement) due to some potentially remediable or preventable cause. The National Health Service and the Community Care Act define ‘need’ as the requirement of the individual to achieve, maintain and restore an acceptable level of social independence and quality of life. Within the domain of health care a ‘need’ is defined as lack of health or welfare or lack of access to care.
Considering serious mental illnesses most of the studies have assessed the needs of patients with schizophrenia and bipolar disorder, but very few studies have evaluated the ‘need’ of patients with other severe mental disorders. The most consistently reporting ‘needs’ by the patients of schizophrenia in various studies were fare management of psychotic symptoms, need for company, need for food, need for information about the illness, looking after home, daytime activities, relief of psychological distress. Significant positive considerations have been reported between number of ‘needs’ and severity of psychopathology.
Very few studies from India have evaluated the ‘needs’ of patients with mental disorders. There is no comprehensive data with respect to the ‘needs’ of patients with severe mental illnesses from India. ‘Needs’ of patients also vary from one side to another depending on the services provided to the patients. Hence it cannot be generalized to others. Thus it is important to study the ‘needs’ of the patients in the specific treatment setting. Understanding the unmet needs of the patients will help in improving treatment and outcome.
The aims and the objectives of the study are to assess the health care ‘needs’ of the patients with serious mental illnesses as perceived by themselves and their primary care-givers. Using Camberwell Need Assessment Scale and indigenously designed Need Assessment Questionnaire. Examination of association between demographic and clinical variables, quality of life, level of functioning and health care needs was planned to be done.
75 patients with diagnoses of serious mental disorders ( schizophrenia, bipolar disorder, recurrent depressive disorder and obsessive compulsive disorder ) were assessed cross-sectionally and their primary care-givers were assessed regarding assessments of ‘needs’ of the subjects in the time-frame of past one month. The subjects were also assessed by Global Assessment of Functioning Scale (GAF) and individual rating scale such as PANSS for schizophrenia, HDRS for recurrent depressive disorder, HDRS and YMRS for bipolar disorder to assess clinical remission among the sample subjects. The findings will be analyzed and documented in detail following completion of assessment.
A cross-sectional and short-term study of patients with dissociative disorders.
Dr Kathakali Chatterjee
Dr D G Mukherjee,
Dissociative disorders previously known as hysteria or hysterical conversion have generated inquisitiveness among mental health professionals for many years. Currently In both International Classification of Disease-10th Edition(ICD-10) and Diagnostic and Statistical Manual of Mental Disorders-IV Edition(DSM-IV) dissociative symptoms are regarded as arising from emotional conflict. But both take divergent approaches to the relationship of conversion disorders to dissociative disorders.
This difference in classification systems has complicated the the concept of dissociative disorder. Since at no time definition of dissociation disorders, conversion disorders, and hysteria were uniform, the outcome studies suffer from the differences in the sample selected.
The purpose of the study is to follow-up a homogenous sample of patients with dissociative disorders diagnosed by DCR of ICD-10 to assess course & psychiatric outcome at the end of the study following intervention
Patients attending Psychiatry Out Patient Department, aged 18-55years who will fulfill the inclusion and exclusion criteria and diagnosed as having dissociative disorder as per DCR 10/DSM-IV would make the cases. Complete history and results of psychological testing will be recorded in a self-made proforma and then the data will be transcribed onto an excel database.
Tools that will be used are- Case history proforma, ICD 10 Diagnostic Criteria for Research, DSM-IV, Dissociative Disorder Interview Schedule and Dissociative Experience Scale.
Then the cases will be regularly followed up following intervention. The intervention will be uniform for all cases with anti-depressants and counseling.
Follow-up assessment of cases will be done after six months and one year for the assessment of dissociative symptoms.
It will be seen whether symptom dimensions can distinguish dissociative disorder from other disorder and whether subtypes are distinguishable from one another by differential association with external variables.
Family history will be studied to see familial clustering.
An Assessment of anxiety and Depressive Disorders in children attending Paediatric and Psychiatric Out Patient Department in a tertiary care hospital .
Dr. Shatabdi Saha,
PROF. DR. D G Mukherjee
DR. Saswati Nath, Associate Professor
BACKGROUND-Child and adolescent anxiety disorders are the most prevalent forms of childhood psychopathology, affecting about 10-20% of children and adolescents at some point in their lives . Separation anxiety and specific phobias are more common in preadolescent children . Female children and adolescents have higher rates of anxiety disorder. Depressive disorder in children is also very common but often remain unrecognized.
OBJECTIVE- to estimate the extent and severity of anxiety and depressive disorder in children and assesment of effectiveness of psychiatric interventions in children with anxiety disorder.
METHOD-All consecutive new children aged between 6-12 year , attending psychiatric and pediatric OPD from 01/07/2014 to 31/12/2014 who are not suffering from mental retardation, epilepsy or any neurological disorders are screened with CBCL. Detailed assessment is done by a semi-structured interview schedule and final diagnosis is done by according to DSM 5- criteria. Severity of anxiety in children is assessed by PARS and severity of depression is assessed with CDRS before intervention and at 6 months after intervention. Statistical analysis is done with SPSS version 20. Paired- t-test is done to assess the effectiveness of intervention.
“A study of outcome of Acute and Transient Psychotic Disorder after a short term follow up in a tertiary care hospital”
DR.Selim Malik, Post-Graduate Trainee
DR. Saswati Nath, Associate Professor
BACKGROUND:
The tenth revision of the International Classification of Mental and Behavioural Disorders (ICD-10) introduced the 'Acute and transient psychotic disorders'(ATPD) {category F23} to incorporate clinical concepts such as the French bouffée délirante, cycloid psychosis (Germany), and the Scandinavian reactive and schizophreniform psychoses. The exact incidence and prevalence of acute and transient psychotic disorder in not known but it is generally considered uncommon. This disorder occurs more often in younger women of developing country (20s and 30s) from low socioeconomic status and in those who experienced disasters or major cultural changes (e.g. immigrants). Approximately half of the patients who are first classified as having acute and transient psychotic disorder later display chronic psychiatric symptoms such as schizophrenia and mood disorder. Patients with ATPD , generally have good prognosis and European studies have indicated 50- 80% of all, patients have no further major psychiatric problem. Schizophrenia and other chronic psychotic illnesses are debilitating disorders and the symptoms and behavior associated with psychosis and schizophrenia have a distressing impact on the individual and the family. So stabilization of patients in acute phases and avoidance of relapse are major objectives of management of this disease.
OBJECTIVES :
General Objectives:-To assess the outcome of ATPD after a short term follow up and factors influencing its outcome so that stabilisation of patients in acute phase and prevention of its chronicity can be done by controlling these factors.
Specific Objectives :-To study the socio-demographic profile of patients with acute and transient psychotic disorder and the outcomes of acute and transient psychotic disorder after a short term (6 months) follow up.
METHOD-All consecutive new patients aged between 15-45 years who fulfill the inclusion and exclusion criteria and diagnosed as having acute and transient psychotic disorder as per ICD 10- DCR (Diagnostic Criteria for Research) criteria , attending psychiatric OPD from 2014 – 2015(1 year ), are screened using a screening tool- Brief Psychiatric Rating Scale (BPRS). Complete history and results of psychological testing are recorded in a case history proforma. Positive and negative symptoms of psychosis are assessed using PANSS. After that their social support is assessed using a Social support questionnaire.. All patients having ATPD are given pharmacotherapy or psychotherapy or both and are followed up each month for 6 months along with use of BPRS and PANSS for assessing any changes in symptomatology. Outcome of Acute psychosis cases after six month follow up are divided into different categories according to ICD 10- DCR. Correlation are assessed between predictor variables and outcome categorical variables.
“A short term comparative study of depressive episodes in Major Depressive Disorder and Bipolar Disorder”
Dr. Arijit Mondal
Dr. Sayanti Ghosh, Associate Professor
BACKGROUND : Distinguishing between major depressive disorder and bipolar disorder is important because there are differences in the optimal management of these conditions. Antidepressant treatment of bipolar depression can adversely affect long-term prognosis by causing destabilisation of mood and more frequent depressive episodes, and can lead to the development of treatment resistance. Most people with bipolar disorder experience depression rather than mania as their first episode of illness. It is clinically desirable to recognise, or at least to suspect, bipolar depression at an early stage of a bipolar illness.
OBJECTIVES:-The main focus is comparative study of socio-demographic profile, family history, clinical features and outcome of those depressed patients with the diagnosis of major depressive disorder and bipolar disorder. Comparison of depressive episodes in major depressive disorder and bipolar affective disorder on the basis of:
(a) Socio- demographic factors
(b) Family history
(c) Clinical features
(d) Outcome following intervention
in a tertiary care general hospital, psychiatry unit.
METHOD : A short longitudinal study. Patients are included using ICD-10 DCR. Sociodemographic pfofile questionnaire, Beck Depression Inventory and Depression Outcome Module are administered during each visit. Patients will be assessed at 0, 1 month and 6 months after initial follow up.
