Mortality in schizophrenia: A study of verbal autopsy from cohorts of two rural communities of South India.

BACKGROUND: Schizophrenia is a life-shortening disease. Although the rate of mortality of persons with schizophrenia in India is established to be more compared to that in the general population, there is a little exploration of the causes for the same. AIM: The aim of this study is to explore the causes of death in two rural cohorts of schizophrenia. MATERIALS AND METHODS: In-person interviews of primary caregivers of 53 deceased persons with schizophrenia were conducted using the World Health Organization's verbal autopsy 2014 instrument. Physician-based method was used to determine the causes of death. RESULTS: Average age of 53 deceased schizophrenia patients was 50.45 ± 13.65 years with almost equal gender ratio. Just more than two-thirds of patients were married, just more than one-third are educated up to primary school and also had no formal education each. Noncommunicable diseases (NCDs) were the most common causes of death (30, 56.6%) in this sample, followed by communicable disease (7, 13.2%), and then unnatural deaths (suicide - 8, 15%, and road traffic accidents - 3, 5.6%). CONCLUSIONS: It is the first study in India to explore the causes of death in schizophrenia. NCDs being the most common cause of death in schizophrenia suggests to the need of integration of schizophrenia care into general health care.

Prevalence & correlates of areca use among rural south Indian schizophrenia patients: A comparative study with general population.

Aims of this study were to compare the prevalence of areca use among schizophrenia patients and general population of a south Indian rural community and to study the correlates of areca use among patients. A cohort of 300 schizophrenia patients, who are being followed up as a part of a community intervention program, formed the study group. The control group (n=382) was selected randomly from the general population of this region. Both were interviewed regarding the sociodemographic details, use of areca nut, alcohol and tobacco. Among patients, Positive and Negative Syndrome Scale (PANSS), Simpson's Angus Scale (SAS) and Indian Disability Evaluation and Assessment Scale (IDEAS) were applied. Use of antipsychotic and anticholinergic medications was also noted. These clinical correlates were compared between users and non-users. The prevalence of areca use among schizophrenia patients was significantly higher when compared to the general population (39.0% vs 14.4%, p<0.001). There was no significant difference in positive symptoms, negative symptoms, extrapyramidal symptoms, antipsychotic and anticholinergic drug dosage between areca chewers and non-chewers. Areca use is significantly higher among schizophrenia patients of this rural area when compared to that among the general population. Considering the health hazards that areca abuse may lead to, this issue needs attention.

Antipsychotic treatment, psychoeducation & regular follow up as a public health strategy for schizophrenia: Results from a prospective study.

BACKGROUND & OBJECTIVES: In low- and middle-income countries such as India, a feasible public health strategy could be to ensure continuous antipsychotics and psychoeducation for those with schizophrenia. Whether such a strategy favourably influences its course and outcome is not well-studied. The objectives of this study were to examine these issues in a cohort of patients with schizophrenia in a rural south Indian taluk (an administrative block). This cohort was part of a community intervention programme running in the place since the past one decade. METHODS: A total of 201 patients were assessed after an average of four years of follow up. Psychopathology, disability and course of illness were assessed using Positive and Negative Syndrome Scale (PANSS), Indian Disability Evaluation and Assessment Scale (IDEAS) and Psychiatric and Personal History Schedule (PPHS), respectively. Interventions included ensuring continuous antipsychotic treatment and low-intensity psychoeducation. RESULTS: One hundred and forty two [70.6%; 95% confidence interval (CI): 64.35-76.95] of the 201 patients achieved clinical remission by the end of follow up period (four years); 140 (69.6%; 95% CI: 63.29-76.07) had satisfactory outcome (42.3% best outcome and 27.4% intermediate outcome). There was a significant reduction in the proportion of patients with disability [134/201 (66.7%) at baseline; 55/201 (27.3%) at follow up; PInterpretation & conclusions: Treatment with antipsychotics and psychoeducation can favourably influence the course of schizophrenia and reduce disability in a substantial proportion of patients. Structured psychosocial interventions may be indicated in the significant minority who show suboptimal outcome with this strategy.

Reasons for Schizophrenia Patients Remaining out of Treatment: Results from a Prospective Study in a Rural South Indian Community.

BACKGROUND: A few studies have examined the factors associated with schizophrenia patients remaining untreated in India. MATERIALS AND METHODS: We identified 184 schizophrenia patients in a rural community, offered the treatment with antipsychotics and followed them up in their Primary Health Centers for 1-year. Twenty-nine (15.8%) patients remained untreated at both the baseline and 1-year follow-up despite our best attempts to keep them under the treatment umbrella. They were interviewed in detail regarding the reasons for remaining untreated. This group was compared with another group of patients (n = 69) who had stopped the treatment at baseline but were successfully brought under the treatment umbrella throughout the 1-year follow-up period. RESULTS: The reasons for remaining untreated were (n; %): (a) Unsatisfactory improvement with previous treatment attempts (19; 65.5%), (b) poor bond between the patients and the families (6; 20.7%), (c) active symptoms not allowing any treatment efforts from the family members (6; 20.7%), (d) magico-religious beliefs about the illness and its treatment (4; 13.8%), (e) poor social support (3; 10.3%), (f) adverse effects of the medications (2; 6.9%), and (g) perception of recovery and cure (1; 3.4%). For many patients, a constellation of these reasons was responsible for them remaining untreated. In contrast, the common reasons for those who restarted medications to have stopped the treatment at some time were the lack of awareness, the need to continue medications (47; 68.1%), and the financial constraints (28; 40.6%). CONCLUSION: The predominant reason for schizophrenia patients not remaining on the treatment in this rural community was the families' lack of faith in antipsychotic treatment. Provision of comprehensive treatment package including medical, psychosocial and rehabilitative services, and sensitizing the community about benefits of the treatment may help in ensuring that all patients with psychosis receive the best care.

Alcohol use disorders in patients with schizophrenia: comparative study with general population controls.

OBJECTIVE: To compare the prevalence of Alcohol Use Disorders (AUD) among schizophrenia patients with that of the general population in a south Indian rural community. METHODS: Alcohol use pattern of 254 schizophrenia patients in the past year was compared with randomly selected healthy comparison subjects (n=350) from the same community in an administrative block of rural India using the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: A significantly smaller proportion of patients used alcohol in the past year (10.2%; 95% CI: 6.5%-14.0%) than controls (18.3%; 95% CI: 15.8%-24.1%; OR=2.2; 95% CI=1.4-3.5). This was true for AUD (hazardous use and harmful use; total AUDIT score >8) also: 5.5% patients (95% CI: 2.7%-8.3%) and 10.3% controls (95% CI: 7.1%-13.4%) had hazardous use (OR=2.0; 95% CI=1.0-3.7). Hazardous use was associated with domicile in villages and lesser years of education. On logistic regression, after controlling for these confounds, the odds of having AUD were 2.7 times more for controls than for patients (95% CI=1.4-5.2). CONCLUSIONS: Prevalence of AUD is significantly lower in patients than in the general population in this community. Cross-cultural studies are needed to elucidate factors that underlie contrasting results across different countries.

Caregiver burden is associated with disability in schizophrenia: results of a study from a rural setting of south India.

BACKGROUND: Taking care of patients with schizophrenia is a major source of burden to the family. Research on burden experienced by family members of patients living in rural communities is sparse. METHODS: Data were obtained from a community intervention program for psychoses in a rural community of south India, where persons with severe mental disorders were identified, treated and followed up. As part of the program, caregivers of 245 schizophrenia patients were interviewed using the Burden Assessment Schedule. Psychopathology (Positive and Negative Syndrome Scale; PANSS), treatment status and disability (Indian Disability Evaluation and Assessment Scale; IDEAS) experienced by the patients were also assessed. Univariate and multivariate analyses were used to study the influence of different factors on the caregiver burden. RESULTS: Level of burden had a significant direct correlation with disability (Pearson's r = .35; p < .01) and severity of psychopathology (r = .21; p < .01). Duration of treatment had an inverse correlation with burden (Pearson's r = -.16; p < .01). Multivariate analysis revealed that total IDEAS score (Beta = .28; t = 4.37; p ≤ .01), duration of treatment (Beta = -.17; t = -2.58; p = .01), age of the family caregiver (Beta = .15; t = 2.4; p = .02) and gender of the patient (Beta = -.13; t = -2.1; p = .04) were significant predictors of burden. The model including total IDEAS score explained 14% of variance (adjusted R (2) = .139; p < .01). CONCLUSION: Burden experienced by family caregivers of schizophrenia patients depends on the level of disability experienced by the patient, age of the family caregivers and gender of the patient. Interventions to reduce disability of the patients may reduce the caregiver burden.

Metabolic syndrome among schizophrenia patients: study from a rural community of south India.

Though metabolic syndrome (MS) is a major concern in schizophrenia, there is no data among rural community dwelling patients in India. This study describes prevalence and correlates of MS in a cohort of schizophrenia patients from a rural community of south India. 171 patients with schizophrenia were screened for the presence of MS using the International Diabetes Federation (IDF) criteria. 94.8% were receiving atypical antipsychotics for a mean (SD) duration of 13.04 (9.51) months. Fifty-four of the 171 (31.6%) patients screened met criterion for central obesity. Of these, laboratory results (fasting blood sugar, triglycerides and HDL cholesterol) were available for 47 patients. The rest 7 were deemed to have met the criteria for MS in order to avoid under-estimation of the syndrome. Only 22 (12.86%) patients met the criteria for MS thus defined. Females were significantly likely to have both central obesity and MS than males. No other predictors of metabolic adverse effects could be identified. Biological and the prevailing socio-cultural factors may contribute to such considerably low prevalence of metabolic abnormalities. Lack of data from a control group forms the most important limitation of this study.

Work functioning of schizophrenia patients in a rural south Indian community: status at 4-year follow-up.

PURPOSE: This report describes the work functioning of schizophrenia patients receiving antipsychotic treatment in a rural south Indian community and examines the factors associated with it. METHODS: We assessed work functioning of 201 patients who have completed a minimum of 3 years of follow-up as part of a cohort study of schizophrenia patients receiving community-based treatment. 'Work' section of the Indian disability evaluation and assessment scale (IDEAS) was used to evaluate work-related disability at the time of recruitment and after a mean (SD) 47.0 (9.6) months of follow-up. Patients with moderate to profound work-related disability were compared with those with no or mild disability across socio-demographic and clinical variables. RESULTS: 75 (37.3 %) were agriculturists; 58 (28.9 %) were pursuing household jobs; 28 (13.9 %) were daily wage labourers; 7 (3.5 %) were skilled labourers; 7 (3.5 %) were involved in other jobs. 26 (12.9 %) were not doing any sort of work. The proportion of patients with moderate or profound disability reduced from 137/201 (68.2 %) at baseline to 82/201 (40.8 %) at follow-up (p < 0.001). Work-related disability reduced significantly [mean (SD) work score on IDEAS was 2.2 (1.6) at baseline and 1.1 (1.2) at follow-up; t = -9.1; p < 0.001]. Logistic regression analysis showed that work-related disability was significantly associated with male gender, longer duration of illness, higher psychopathology and poor treatment adherence. CONCLUSION: Nearly two-thirds of schizophrenia patients living in this rural south Indian community had satisfactory work functioning, a rate, which is substantially higher than rates reported from high-income countries. Agrarian work atmosphere and rural sociocultural milieu may have contributed to this in our sample. However, substantial proportion of patients remains considerably disabled. This highlights the need for concerted, community-level efforts to improve their functioning.

Do antipsychotics limit disability in schizophrenia? A naturalistic comparative study in the community.

BACKGROUND: Though antipsychotics are effective against symptoms of schizophrenia and prevent relapses, their effect on disability has not been studied in a comparative design. AIM: To compare disability of schizophrenia patients receiving continuous antipsychotic treatment with that of those not receiving or receiving irregular treatment in a rural community setting using a naturalistic comparative study design. PATIENTS AND METHODS: Disability was assessed in 182 schizophrenia patients living in Thirthahalli Taluk of Shimoga District, Karnataka, using Indian Disability Evaluation and Assessment Scale (IDEAS). Fifty patients (27.5%) were receiving regular treatment in the previous 2 years and their disability was assessed for the period when they were on antipsychotics. The remaining 132 patients (72.5%) had off-antipsychotics periods in the previous 2 years and their disability was assessed for the period when they were off-antipsychotics. RESULTS: Patients on antipsychotics had significantly less disability across all domains of disability and in total IDEAS scores. Multivariate regression analysis showed that treatment status predicted disability scores after controlling for the effects of the confounding factors. Different levels of exposure to antipsychotic treatment were associated with different levels of disability. CONCLUSIONS: Treatment with antipsychotics is associated with significantly less disability. There is an urgent need to bring schizophrenia patients under the umbrella of treatment.

Sex difference in age of onset of schizophrenia: findings from a community-based study in India.

This study examined the sex difference in age of onset of schizophrenia in a community sample. Community-level health workers identified patients with symptoms of schizophrenia living in the community in a defined geographical area in South India. Two hundred and nine of them were diagnosed as hav-ing schizophrenia according to ICD-10 criteria by a team of psychiatrists. The age of onset of schizophrenia was assessed using the Interview for Retro-spective Assessment of Onset of Schizophrenia (IRAOS). The mean age of onset of schizophrenia did not significantly differ between males (29.2+/-8.8 years) and females (30.8+/-11.4 years) (t = 1.12; p = 0.27). Among those with an age of onset 33 years, females had a significantly later onset. The results from this community-based study confirm the previous findings in hospital-based patients in Asia. There is a need to revise the description of schizophrenia in the classificatory systems, keeping in view the regional varia-tions in the age of onset of the disorder.