schizophrenia research in india

Schizophrenia Research in India: 

Schizophrenia Research in India shinevayala@gmail.com

INDIAN RESEARCH: 

INDIAN RESEARCH

Review of: : 

Review of: Epidemiology Course And Outcome Untreated Psychosis Phenomenology Age At Onset Family In Schizophrenia Disability General Excluded: Treatment Rehab Drug Trials Side effects Biological work Case histories

Epidemiology : Prevalence: 

Epidemiology : Prevalence 2.6/1000 ( Surya, 1964) and 3.4/1000 ( Sethi et al). Sample sizes : 674(Nandi 1980) to 101,229 (Padmavati 1988). No consistent rural- urban differences in the frequency of the illness. More in the urban slums, (Padmavati ’88; Brahmins (7.2/1000 as compared to scheduled castes (1.8/1000), higher socio-eco.class (Varma’80).

Epidemiology:INCIDENCE: 

Epidemiology:INCIDENCE Higher in India than the West ( W. Bengal-Nandi’76;Chandigarh – Varma’89; and Madras, Rajkumar, ’91) Incidence rates- 0.35/1000 to 0.38/1000 (urban) & 0.44/1000 (rural) ( Rajkumar 1993). No male- female differences. 0.38/1000 (urban) & 0.44/1000 (rural) (Varma’89). Highest amongst rural females.

*Indian figures comparable to those from the west * No high pockets of prevalence /incidence. * No significant gender differences *Age at Onset : no gender differences : 

* Indian figures comparable to those from the west * No high pockets of prevalence /incidence . * No significant gender differences * Age at Onset : no gender differences

Course & Outcome: 

Course & Outcome International Pilot Study of Schizophrenia – IPSS (WHO 1973) -Major transcultural work done in 9 countries Standardized methods of case identification and assessments, 1202 pts. Agra – Indian centre ( K C Dube)

IPSS : RESULTS: 

IPSS : RESULTS Better outcome was seen in AGRA in terms of : - Symptoms -Length of episode of inclusion -Time spent in psychotic episode At 5 yrs: Best Outcome Agra - 42% Aarhus – 6% London – 5%

Chandigarh studies: 

Chandigarh studies DOSMED: 10 Countries, Chandigarh ( rural & urban) ( Sartorius 86) 2 yr. Outcome was better. Kulhara & Chandiramani(1988) 112 pts. Outcome : good & not influenced by diagnostic criteria used.

SOFACOS (ICMR): 

SOFACOS (ICMR) Vellore, Madras, Lucknow: 386 patients Most : first episode ICD –9, modified Feighner Inclusion : PSE, PPHS, IFS- every month Repeat every year Five year follow-up Outcome – multidimensional- clinical, social, occupational Intercentre comparisons

SOFACOS : Results: 

SOFACOS : Results FUP rate of 75% at end of 5 years 67% of patients had Good Outcome No difference between centres Absence of dangerous behaviour, drug compliance, younger age at onset, rural background, absence of economic difficulties. No marked gender differences Disability ( SAPD) % EE : off shoot studies.

Madras Longitudinal Study (Thara): 

Madras Longitudinal Study (Thara) Prospective FUP till 10 years Results analysed in collaboration with JHU Included in the ISOS (WHO) Fup at 20 years (2001-2002) Over 15 publications

Slide 14: 

4 (6.5%) 1 (1.6%) 24 (39.3%) 27 (44.2%) 5 (8.1%)

Marriage in Schizophrenia: 

Marriage in Schizophrenia Marriage and gender in schizophrenia - rate of marriage : high in Indian pts - 80% of marriage were intact at follow up over 10 years - more women had broken marriages - continuous/relapsing course in both sexes reduced the prospect of getting married - socio-cultural attitude Thara & Srinivasan - 1997

Work in Schizophrenia : 

Work in Schizophrenia Males : Over 60% had good work functioning at 10 years. associated with overall clinical, social and marital outcome.(Srinivasan & Thara, 1997) Females : House making function in woman is related to clinical and social outcome, which can be equated with paid employment in men. (Srinivasan & Thara, 1992).

Age of Onset: 

Age of Onset traditional view of a younger age at onset of schizophrenia among males. No difference : SOFACOS Age at onset, first contact , first appearance of symptoms- ND( Murthy et al, 1998) Perinatal complications might account ( Gangadhar et al 2002 )

Phenomenology : 

Phenomenology 39.5% of the 386 pts. at inclusion had catatonic syndrome on the PSE; dropped to 4% at the end of 5 years follow up. (ICMR SOFACOS’92) >15 catatonic pts. (IPSS, Agra ‘79) Symptoms vary in different cultures (Varma ’92).

Family and Schizophrenia: 

Family and Schizophrenia Initial efforts – to compare routine treatment with family ward treatment. (Narayanan & Reddy ’68; ’72, ’77; Geetha et al ‘80) Family and group processes (Bhatti & Verghese ’95) Pos. family attitude (ICMR Facos 1988, Verghese 1989) Reduced relapse rates (Shankar ’98) Participation of families in therapeutic programmes (NIMHANS; CMC Vellore, SCARF)

Family Research: 

Family Research FAMILY EE Burden COPING STIGMA FBS BAS Disability

Religious Treatment: 

Religious Treatment Raghuram et al, Thara et al, Chadda et al Decision taken by families Based on the explanatory model Varying degrees of improvement Varying methods of “cure”

Coping strategies: 

Coping strategies Coping strategies used by families of chronic mentally ill are similar to those of chronic medical illness are help seeking, diversion, religious, positive thinking & avoidance. (Puttamma et al - 1998) Indians used less coping strategies than Germans. (Kumar et al. 1994).

Disability Research: 

Disability Research Field Trials of International Classification of Functioning ( ICF)- formerly ICIDH- Delhi, Chennai & Bangalore Field testing of WHO-DAS II Most health professionals unfamilar with the concept of disability, especially that of MENTAL DISABILITY

Disability : 

Disability Profile and nature of disabilities in schizophrenia and other disorders such as MDP etc . Role of intervention Longitudinal course of disability ( SOFACOS, MLS) Disability vs Burden, Stigma, Psychopathology . Small sample, student dissertations

Measures of Disability: 

Measures of Disability Chandigarh ( Pershad et al) SAPD ( Thara et al, 1988) SSFI ( SCARF) IDEAS ( IPS, 2001) WHO DAS II

Untreated Schizophrenia SCARF studies: 

Untreated Schizophrenia SCARF studies Why they remain untreated? Phenomenology and course Abnormal Movements with a follow -up AM in family members MRI studies

Movement disorders in Untreated Schizophrenia : 

Movement disorders in Untreated Schizophrenia Involuntary movements similar to drug induced tardive dyskinesia Memory dysfunction, changes in volume of basal ganglia, increased prevalence of IM in unaffected first degree relatives Appearance of dyskinesia in previously symptom-free pts. during follow up. (Mc Creadie et al 1996, 2002a, 2002b)

MRI STUDY: 

MRI STUDY Left Lentiform Nucleus significantly bigger than Normal controls in Schizophrenia with Spontaneous D. Normal regression in size of BG does not occur with age in Schizophrenia

Schizophrenia that was never treated in an urban community: 

Schizophrenia that was never treated in an urban community 100,000 pop. of Chennai: door-to-door survey: 66000 above 15 years Four state run hospitals (in 5 km radius) offering free/low-cost treatment 261 with schizophrenia (ICD-9) Mean duration 12 years All living with their families

Slide 33: 

URBAN SURVEY- SCHIZOPHRENIA PATIENTS

Slide 34: 

Response to the call to get treated

Slide 35: 

Clinical Outcome Pattern of Course Occupational Outcome Male= Employment Status + Work Performance Female = Performance of Housework Social Outcome Social Impairment due to psychiatric condition + Social network Global Outcome Good = If Good outcome in at least two areas OUTCOME MEASUREMENT Using PSE and PPHS

Slide 36: 

How was the Outcome related to Duration of Untreated Psychosis? Global Out come poorer with longer DUP Occupational Out come poorer with longer DUP Social Out come not clearly related to DUP Clinical Out come poorer with longer DUP Longer the psychosis is left untreated Worse is the response to treatment

Slide 37: 

Symptom Patients Lack of judgment/insight (Gen) 97 (68%) Delusion (Pos) 95 (66%) Suspiciousness/persecution (Pos) 90 (63%) Concept Disorganization (Pos) 82 (57%) Hall. behavior (Pos) 76 (53%) Difficulty in abs thinking (Neg) 67 (47%) Passive/Apath Soc. withdrawal (Neg) 65 (45%) Hostility (Pos) 60 (42%) Blunted affect (Neg) 55 (39%) Emotional withdrawal (Neg ) 55 (39%) PANSS- Most Common symptoms

Psychopathology in never treated: 

Psychopathology in never treated Positive symptoms occurred frequently Psychopathology not related to gender, age , duration of illness and age at onset Positive and negative symptoms negatively correlated with each other Some differences from treated patients

Extrapyramidal symptoms in the never treated subjects: 

Extrapyramidal symptoms in the never treated subjects Dyskinesia = 50 (35%). Parkinsonism = 22 (15%) Dyskinesia only=39 Parkinsonism only= 11 Both = 11

EPS and variables: 

EPS and variables No Gender differences Not related to age

Issues – Untreated schizophrenia: 

Issues – Untreated schizophrenia Living with large families who look after the disabled person who is under little or no demand to perform BUT The never treated were severely disabled Effect of treatment on clinical recovery limited Hence need to get the never treated to treatment early

MISCELLANEOUS ….: 

MISCELLANEOUS …. Stigma : WPA MULTI SITE STUDY (Murthy et al, Thara & Srinivasan, 2000) Dual Diagnosis Concept of Insight is multidimensional and there is a need to focus future studies on the difference between dimensional & global measures of insight. (Tharyan & Saravanan 2000

Contd…: 

Contd… Quality of Life : need to use proxy measures as interviews of key informants (Lobana, Basu et al, 2001) Smoking in schizophrenia 286 urban male outpatients - only 38% were found to be current smokers. significantly more than in other psychiatric patients studied (major affective disorders and non-psychotic disorders) but not medically ill controls and not higher than the rates in GP. Economic reasons ( Srinivasan & Thara, 2001)

Schizophrenia Research : Most exciting and intriguing of all mental health research Grave yard of researchers!! :: 

Schizophrenia Research : Most exciting and intriguing of all mental health research Grave yard of researchers!! :

NAMASTHE: 

NAMASTHE shienvayala@gmail.com