Rehabilitation need assessment of severely Mentally ill and effect of Intervention

Transcription

1 APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 Original Article Rehabilitation need assessment of severely Mentally ill and effect of Intervention T.B. Singh*, G.S. Kaloiya*, Sanjay Kumar**, R.K. Chadda*** *Department of Clinical Psychology, Institute of Human Behaviour and Allied Sciences, Delhi **School of Psychology, University of Birmingham, U.K. ***Department of Psychiatry, AIIMS, New Delhi ABSTRACT To study the rehabilitation needs of severely mentally ill person and to ascertain the efficacy of intervention strategies to meet out these needs, a group of 50 severely mentally ill persons, 25 each in experimental and control group as per proposed inclusion and exclusion criteria were selected from indoor and out patient clinic of IHBAS as sample of the study. Intervention package used in the study included psycho-education, activity scheduling and social skill training. To see the effect of intervention parameters used were symptom reduction, disability remediation, subjective wellbeing and dysfunction in social, family, personal, vocational and cognitive areas. Rehabilitation need assessment schedule, Mini Mental Status Examination, Positive and Negative symptom scale, Disability Assessment Schedule, Subjective well being Inventory and Dysfunctional Analysis Questionnaire were administered to collect desired data twice in the pre and post intervention phases. Pre assessment followed intervention sessions conducted for the experimental group for eight weeks duration. During this period control group subjects were waitlisted for this intervention. Results indicated that intervention is effective in symptom reduction, disability remediation, improving subjective well being and functioning in personal, social, family and cognitive areas. Key words: Rehabilitation needs, psychosocial intervention, disability and dysfunction. Introduction Curative efforts have usually remained the focus in the post independence era of mental health services in India. Although scanty efforts have been made in the area of psycho-social rehabilitation; which is now becoming a priority area day by day due to increasing population of severely mentally ill in the country. Agarwal s 1 apt remark our forgotten millions about severely mentally ill of the country signifies that we have paid more attention only to treatment and really forgotten the severely mentally sick persons of the country. Kulhara 2 felt that this population has remained a neglected lot and now active action oriented efforts are needed to manage and rehabilitate this neglected population. Kapur 3 advocated need for suitable assistance to the families of managing severely mentally ill in the rural areas. According to Kulhara 2, nearly 300,000 and 105,000 cases of schizophrenia are added every year in rural and urban population respectively. Out of these 40-60% cases go through the phase of chronic and suffer impairment and disabilities. Thus it is evident that roughly 150,000 or more people suffering from schizophrenia are added every year to the country s post of disabled schizophrenic population. Extent of the problem The prevalence of schizophrenia varies from 2-3/1000 all over the world. Indian researchers have also reported similar rates ranging from 0.9 to 4.3/ Wig et al. 7 noted an incidence of 4.47/10,000 in rural area and 3.8/10,000 in urban area. Above 109

2 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010 figures give an estimate that there will be approximately 2 million persons suffering from schizophrenia at any given point of time. Affective disorders are now conceptualized as chronic illnesses and the earlier notion of a better prognosis is being replaced with the acceptance of the fact that very few patients of affective disorder have a single episode, majority have relapsing course and 10-20% have chronic course. 8 Overall lifetime prevalence for major depression has been found around 5%. The prevalence rates of manic depressive psychosis are reported to be 1.3/ Disability arising out of severe mental illness is defined as an inability to perform at a serially desirable level in such activities i.e. self are, social relationship, work and situational appropriate behavior. Aggarwal 1 outlined that roughly 0.5% to 1% population will have certain disability due to chronic mental illness; barring a few thousand all others are living in the community. Indian researches in the area of psycho-social intervention based rehabilitation of people suffering from mental illness have covered sociological and psychological characteristics of chronic psychiatric population, 8 treatment needs of chronic psychiatric patients, attrition in follow up of schizophrenic 10 nature and course of disability care givers burden and coping 13,14 family burden and it s assessment 15,16 Padmawati el al, Present study was formulated to assess the rehabilitation needs and effect of intervention on severely mentally ill population, counseling dearth of intervention based studies in the Indian context. Methods Aim of the present study was to find out the rehabilitation needs including family burden of chronic mentally ill and to study the effect of intervention. Sample Chronic mental patients under treatment and regular follow ups of out-patient or indoor clinics of Institute of Human Behaviour and Allied Sciences (IHBAS), Delhi, were the universe of the study. Total 50 consecutive patients identified within a period of three months, who fulfilled the inclusion and exclusion criteria, were selected as sample of the study. Patients were divided into experimental and control group alternating one another in sequential manner. Patients with diagnosis of chronic psychosis more than two years with age range between twenty and forty years, can follow simple instructions and on maintenance medication were included. Patients with co morbidity or neurological/ physical illness, having severe side effects of medicines and score on Mini Mental State Examination less than twenty were excluded. Tools Demographic Data Sheet: A data sheet was devised which included the details of the subject s age, sex, education, occupation, marital status, onset of illness, total duration of illness with exacerbation of symptoms, current medication and side effects etc. Mini Mental State Examination (MMSE) 17, MMSE has been used as a screening tool. A score less than 20 (maximum score- 30) signifies poor cognitive functions as they were not able to follow even simple instructions. Positive and Negative Syndrome Scale (PANSS) 18, PANSS is a seven point rating scale ranging from absence of symptom to presence of symptom in terms of its severity. This shows the current picture (within one week) of client s psychopathology. The scale was used in the study to see the impact of intervention strategies on symptom reduction. Rehabilitation Needs Assessment Schedule (RNAS) 19, RNAS covered the: Employment, Vocational training/guidance, Accommodation, Leisure activities, Psychosocial attitudes modification, Skills training, any help needed by the family areas. RNAS collects quantitative information on the subjective needs of the client. Out of total eight items, two items (item 6 and 7) are addressed to key informant, rest all other items are asked from the client. The Schedule for Assessment of Psychiatric Disability (SAPD), 15 The instrument is the modified version of Disability Assessment Schedule (II) of WHO to make this applicable to the existing socio-cultural norms in India. Inter rater reliability carried out for every third case was noted to be 0.92 (Kappa index). Items of this tool are rated by 110

3 APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 interviewing the caregivers of the subjects, considering their functioning over the past one month. Higher scores signify greater degree of disability. Dysfunction Analysis Questionnaire (DAQ), 20 DAQ assesses deterioration/dysfunction due to illness in social, family, personal, vocational and cognitive areas. Clients are rated on this instrument with the help of caregivers rating is done for each area-wise (10 items in one area; total 50 items) on a five point scale. A higher score on this questionnaire shows greater degree of dysfunction. Subjective Well Being Inventory (SUBI) 21 SUBI was developed by WHO considering a priority area which needs to be studied thoroughly. SUBI explores subjective well being as an indicator of quality of life including the perceived quality of social networks. Hindi version of this inventory was made available by Nagpal. 21 Higher scores signify low degree of subjective well being and quality of life. This inventory is filled up by the client himself being a self report of well being. Procedure Referred cases from the Department of Psychiatry were included in the study as per inclusion and exclusion criteria. Initial screening of all the referred clients was done with the help of socio-demographic data sheet and MMSE. Subjects and their caregivers were explained the purpose of this study and their written consent was obtained to participate in the study. Subjects were allotted to groups alternatively to form two groups: experimental and control of 25 subjects in each group. Pre-assessment for all the subjects was done within one week of their enrolments as per requirement and availability of caregivers either in IHBAS or at their native locations in the family. For the experimental group initial assessment was followed by intervention, which commenced with psycho-education for the family and the subjects. Social skills training introduced subsequently, varied from subject to subject according to their needs and deficits. After completion of intervention for 3 months post term assessment was done for both the groups. Control group was waitlisted for the purpose of this research. Intervention training was extended to them after completion of post assessment, i.e. after twelve weeks. Statistical analysis of the data was done using descriptive statistics. Intervention Strategies Intervention strategies used in this study were: Psycho-education, Activity Scheduling, and Skills training including social skills, pre-vocational and vocational training. (Details of intervention are available with the first author). Results Results are presented in tables 1 to 7. Table-1. Indicates the Demographic characteristics of the identified sample Demographic Experimental Control Characteristics group Group (n = 25) (n = 25) Age (mean & SD ± ± 8.12 in years) Age range 21 to to 38 Male Female Education (in years of ± ± 3.17 schooling) Marital Status Single Married Separated Occupation Housewife Unemployed Duration of illness 9.09 ± ± 6.67 Table-2. Assessed rehabilitation needs of the studied subjects in both the groups Rehabilitation Needs % Social skills 80 Employment 65 Providing help for families 60 Leisure activities 45 Vocational training 30 Modifying psychological environment 25 Discussion In the initial phase of the study rehabilitation needs were identified. Assessment of rehabilitation needs indicated that social skills training was the most preferred area of intervention (Table 2) by 80% of subjects of both the groups (Experimental and Control), followed by employment (65%), providing help for families (60%), leisure activities (45%), vocational training (30%) and modification of psychological environment (25%). 111

4 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010 Table 3 Pre and post assessment mean scores of both the groups on MMSE Mean S.D t 7.39** ** Table 4 Pre and post assessment mean scores of both the groups on PANSS Mean SD t 7.36** ** * Significant at.05 level Table 5 Pre and post assessment mean scores of both the groups in SAPD Mean SD t 12.41** ** Table 6.1 Pre and post assessment mean scores of both the groups on DAQ: SOCIAL Mean SD t 8.23** ** Table 6.2 Pre & post assessment scores of both the groups on DAQ: VOCATIONAL Mean SD t

5 APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 Table 6.3 Pre and post assessment mean scores of both the groups on DAQ: PERSONAL Mean SD t 6.99** ** Table 6.4 Pre and post assessment mean scores of both the groups on DAQ: FAMILY Mean SD t 13.39** ** Table 6.5 Pre & post assessment mean scores of both the groups on DAQ: COGNITIVE Mean SD t 12.34** ** Table 7 Pre and post assessment mean scores of both the groups on SUBI Mean SD t 9.26** ** These needs have been classified into four categories being critical to effective functioning i.e., symptom reduction including disability remediation, skill development, social support enhancement and environmental adaptation. Effective service delivery to meet these needs is determined by client s assessment, client s education, professional competencies and outcome evaluation. Observations based on Mini Mental State Examination in the pre-post (experimental group only) and Post (experimental and control) sessions were suggestive of positive effect of intervention on cognitive functions (Table 3) of the subjects of experimental group. They differed significantly from their control counterparts. Menon 22 stressed the role of intervention and its positive effect on 113

6 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010 cognitive remediation. George et al 23 also observed that predominant negative symptoms were responsible for deficits in chronic schizophrenic clients. Improvement in cognitive functions is evident as a result of symptom reduction. Pradhan et al 24 and Chaddha et al 25 noted that symptomatic recovery is usually better and easily achieved than functional recovery. They emphasized the role of psycho-social rehabilitation to achieve functional recovery. Jones 26 stated that cognitive impairment combined with competency screening can be used successfully to identify patients at risk for poor functional status. Change noted here in the cognitive status of the experimental group of subjects as a result of exposure to psycho-education, activity scheduling and social skills training is indicative of the fact that intervention helps in improving the cognitive functions of the chronic mentally ill persons. Subsequently, significant difference between the scores (Table 4) obtained on Positive and Negative Symptom Scale by experimental and control group in Pre-Post and Post-Post assessments further validates the observation that intervention given was helpful in symptom reduction. Disability remediation with the help of skill training. 22,27,28 Results based on assessment of psychiatric disability were in conformity with observation made by these authors. Pre-post and post-post assessment scores of experimental group indicated significant decrease in psychiatric disability. Findings further suggested that contr ol group deprived of intervention scored higher on disability scale and showing increase in psychiatric disability (Table 5). These observations suggest that interventions of psycho-social nature play an important role in minimizing psychiatric disability of chronic mentally ill. Thara and Srinivasan 15 reported similar results based on their study. Dysfunction in the area of social, vocation, personal, family and cognitive caused by chronic mental illness (Table 6.1 to 6.5) was analyzed in this study with the help of Dysfunction Analysis Questionnaire. This analysis also focused on assessing the improvement, which has taken place as the result of intervention given. There was significant positive change in all the aforesaid areas as seen in the scores of experimental group except in the vocational area. This may be due to less or no involvement of the subjects in any vocation due to long duration of chronic mental illness of the subjects. Further, training in the prevocational or vocational skills were not well structured at the time of this study in day care centre of IHBAS. Hence, the same was not included in the intervention package of this study. These findings of Dysfunction analysis supported our earlier observations related to personal and social skills, disability assessment (Table 5) and improvement in cognitive functions (Table 2 & 4). Family area of dysfunction analysis was important 3 as DAQ was filled up with the help of caregivers, who rated their sick family member s dysfunction level in the family. In the post assessment sessions after completion of intervention significant change in rating was noted. Scores of experimental and control group in Prepost and Post-post sessions differed significantly (Table 6.4) which suggests that psycho social intervention was helpful in changing the perception of caregivers who considered them dysfunctional or burden in the family. Subjective well being explored in this study (Table7) as an indicator of Quality of Life has shown favourable results. Scores obtained on Subjective Well Being Inventory by experimental group in the pre-post and post-post assessments indicate positive change in subjective well being (as a measure of Quality of life) of experimental group subjects. Regarding intervention package used in this study, it was observed that psychoeducation used with subjects and their family was helpful in changing the perception of family towards their sick family members (Table 6.4) and also in decreasing perceived family burden. Activity scheduling and social skill training were proved to be useful in improving cognitive function, disability remediation, psychopathology and quality of life in the subjects of experimental group. Limitations of the study Although family (care givers) was focused in the study, as they were included in the need assessment and intervention through Psychoeducation programme and intervention package to address and meet their needs, effects of intervention in terms of acquired skills, measured in the pre and post assessment sessions were confined to day care centre and IHBAS only. Their replication was not 114

7 APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 followed up in the family or community setting due to limitation of and non availability of time. Family visits made during this research work only intended to get rating of caregivers in different areas of rehabilitation need assessment and intervention services introduced. Structured education for the family was conducted mostly in day care centre of IHBAS, Delhi only. Conclusion Severe chronic mental illness, which causes disability in the personal, family and social living of victim, is increasing day by day in the country. Hence, utmost attention is needed to cater to the rehabilitation needs of this population. Management of these clients largely based on use of medicines to manage symptoms. Psychosocial intervention using psycho-education; activity scheduling and social skill training was noted to be effective in symptom reduction, disability r emediation, improving subjective well being, cognitive ability and function in personal, social and family areas. Psycho-social model of rehabilitative effort to help clients suffering from chronic mental illness, used in the study is replicable elsewhere especially in Day care centers, Psychiatric treatment centers and other such institutional agencies. References 1. Agrawal AK. The forgotten millions. Indian J Psychiatry 1998; 40 : Kulhara P. Schizophrenia the neglected lot: Call for action. J Mental Health Human Beh 1997; 2(1) : Kapur RL. The family and schizophrenia: Priority areas for intervention research in India. Indian J Psychiatry 1992; 35(1) : Sethi BB, Gupta SC. An analysis of 2000 private and hospital psychiatric patients. Indian J Psychiatry 1972, 14 : Dubey KC. A study of prevalence and biosocial variables in mental illness in a rural and urban community of Uttar Pradesh, India. Acta Psychiatrica Scandinavia 1970; 86 : Nandi DN, Ajmany S, Ganguli H. Banerjee G, Boral, GC, Ghosh A. Sarkar S. Psychiatric disorders in a rural community in West Bengal: An epidemiological study. Indian J Psychiatry 1975; 17 : Wig NN, Varma VK, Mattoo SK, Behre PB, Phookan HR, Misra AK, Sriniwasmurthy R, Tripathi BM, Menon DK, Khandelwal SK, Bedi H. An incidence study of schizophrenia. Indian J Psychiatry 1993; 35(1) : Stephens JH. Long term prognosis and follow up. Schizoph Bull 1978; 1(4) : Chadda RK, Pradhan SC, Bapna JS, Singhal R. Treatment needs of Chronic Psychiatric patients. J Mental Health Human Behav 2000; 5(1) : Thara R, Rajkumar S, Valecha V. Schedule for the assessment of Psychiatric disability-a modification of the DAS-II. Indian J Psychiatry 1988; 30(1) : Thara R, Rajkumar S. A study of sample attrition in follows up of schizophrenia. Indian J Psychiatry 1970; 32(3) : Thara R, Rajkumar S. Nature and course of disability in schizophrenia. Indian J Psychiatry 1993; 35(1) : Walia A, Singh TB, Shivalkar R. Hospital based cross sectional study of caregivers burden in chronic schizophrenia. Unpublished M.Phil. dissertation submitted to University of Delhi, 2006; Delhi. 14. Chadda RK, Singh TB, Ganguly KK. Caregivers burden and coping: a prospective study of relationship between burden and coping in caregivers of patients with schizophrenia and biopolar affective disorder. Social Psychiatry Epidemiology 2007; 42(4) : Thara R, Srinivasan L. Management of social disabilities in schizophrenia. Indian J Psychiatry 1998; 40(4) : Padmawati R, Thara R, Sriniwasan L, Kumar S. SCARF Social functioning index. Indian J Psychiatry 1995; 37(4) : Folstein MF, Rovner BW. Mini Mental State Examination in Clinical Practice. J Psychiatr Res 1975; 12 : Kay SR, Fiszabein A, Opler LA. Positive and negative symptom scale. Schizophr Bull 1987; 13 : Nagaswami N, Valecha V, Thara R, Rajkumar S, Menon S. Rehabilitation Needs of Schizophrenic Patients: a preliminary report. 115

8 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010 Indian J Psychiatry 1985; 27 : Peeshad D, Verma SK, Malhotra A, Malhotra S. Dysfunction Analysis Questionnaire. National Psychological Corporation, Agra Nagpal R, Sell H. Subjective Well being. Searo Regional Health Papers No. 7, World Health Organization Menon SM. Psycho-social rehabilitation: current trends. NIMHANS J 1996; 14(4) : George RM, Chaturvedi SK, Murali T, Gopinath PS, Rao SL. Cognitive deficits in relation to quality of life in chr onic schizophrenics. NIMHANS J 1996; 14 : Pradhan SC, Sinha VK, Singh TB. Psychosocial dysfunctions in patients after recovery from mania and depression. Interna J Rehabi Res 1999; 22 : Chadda RK, Pradhan SC, Bapna JS, Singhal R, Singh TB. Chronic psychiatric patients: an assessment of treatment and rehabilitation related needs. Inter J Rehabi Research 2000; 23 : Jones BN, Jayram G, Samuels J, Robinson H. Relating competency status to functional status at discharge in patients with chronic mental illness. J Am Acad Psychiatry Law 1998; 26(1): Gopinath PS, Chaturvedi SK. Distressing behaviour of schizophrenics at home. Acta Psychiatrica Scandinavia 1992; 86 : Liberman RP, Wallace CJ, Blackwell G, Kipeliwicz A, Vaccaro JV, Mintz J. Skill training versus psychosocial occupational therapy for persons with persistent schizophrenia. Am J Psychiatry 1998; 155(8) : Acknowledgement: Authors acknowledge the valuable co-operation and financial support in carrying out this research work by PREM DIVISION of Ministry of Social Justice and Empowerment, Government of India. 116