Effectiveness of Social Skills Training Groups in Persons with Severe Mental Illness: A Pre-Post Intervention Study.

Background: The study aimed to evaluate the effectiveness of a social skills training program provided at the occupational therapy unit of a tertiary care center in India. Methods: The study used a pre-post interventional design where 101 consecutive patients with a diagnosis of schizophrenia or bipolar affective disorder, between 18 and 60 years, who provided written informed consent, were assessed on the Vellore Assessment of Social Performance (VASP) during the first week of attendance (baseline). Subsequently, they were enrolled in a six-session social skills group training program for two weeks. They were assessed on the VASP after one week (midterm assessment) and at the end (posttest) of the intervention. A follow-up assessment was done two weeks after cessation of the intervention. The participants were also scored on the Brief Psychiatric Rating Scale (BPRS) at four time points. Results: Repeated measures ANOVA revealed significant differences in the VASP scores between time points, that is, F(baseline, midterm) = -4.34 and P = 0.001; F (baseline, postgroup) = -6.92 and P = 0.001; and F (baseline, follow-up) = -8.71 and P = 0.001. The correlation between the BPRS and VASP scores was also significant at each time point. Conclusion: The social skills group training protocol seems to be effective and feasible for the Indian population. Since conducting multicenter clinical trials might not always be possible in resource-constrained settings, this study might be considered preliminary evidence for context-specific, peer-/family-supported social skills training.

Intrinsic capacity and its associations with incident dependence and mortality in 10/66 Dementia Research Group studies in Latin America, India, and China: A population-based cohort study.

BACKGROUND: The World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach-testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death. METHODS AND FINDINGS: We conducted population-based cohort studies (baseline, 2003-2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008-2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3-76.3 years; 62.4% were female, range 53.4%-67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69-2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49-1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias. CONCLUSIONS: In this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes.

Development and validation of Vellore Inventory of Life Skills among people with severe mental illness.

BACKGROUND AND AIM: Rehabilitation for people with severe mental illness is incomplete without life skills assessment and intervention. The aim of the study was develop a culturally specific performance-based measure assessing life skills of patients with severe mental illness. MATERIALS AND METHODS: The items for the Vellore Inventory of Life Skills (VILS) were drawn after consultation with a reference group and from existing standardized scales. The items were categorized into two sections with six components each, which was further hierarchically arranged into activities at either basic, intermediate, or advanced level. One hundred consecutive clients between 18 and 60 years of age who provided written informed consent were assessed on the Comprehensive Evaluation of Basic Living Skills (CEBLS) and the VILS to evaluate convergent validity and inter-rater reliability. The General Health Questionnaire (GHQ-12) was used to evaluate divergent validity. The assessments were repeated after a week to evaluate test-retest reliability. RESULTS: The scale had good inter-rater reliability 0.938 (95% confidence interval [CI] 0.887-0.967) and test-retest reliability 0.907 (95% CI 0.865-0.937). The correlation between total score of VILS and CEBLS (Pearson's correlation coefficient [PCC] = 0.611; P = 0.001) suggested moderate convergent validity. The correlation between total score of VILS and GHQ-12 (PCC = -0.260; P = 0.105) implied good divergent validity. CONCLUSION: Preliminary data suggest that the VILS is clinically useful for the Indian population.

Development and validation of Vellore Assessment of Social Performance among clients with chronic mental illness.

BACKGROUND: Social skills deficits are hallmark symptoms of chronic mental illness. The absence of a culturally sensitive instrument to measure social skills in the Indian population demands the need to develop and standardize such instruments. AIM: The aim of this study was to develop and validate a context-specific, culturally relevant, and performance-based assessment scale for social performance. MATERIALS AND METHODS: An expert committee of mental health professionals reviewed existing literature, identified standardized scales, examined items for cultural relevance, and identified possible issues for measurement. The items were categorized into 5 domains with a 7-point scale. The instrument was initially piloted on 10 participants, then among 101 consecutive clients with chronic mental illness between 18 and 60 years of age who provided written informed consent. They were assessed by two therapists to evaluate inter-rater reliability and test-retest reliability. They were also assessed on the Social Interaction and Communication Skills Checklist (SICSC) to evaluate convergent validity and on the 12-item General Health Questionnaire (GHQ-12) to assess divergent validity. Standard statistical tests were used to study its characteristics. RESULTS: The scale had good inter-rater reliability (0.941; 95% confidence interval [CI]: 0.914, 0.960) and test-retest reliability (0.928; 95% CI: 0.810, 0.965). The correlation between total score of Vellore Assessment of Social Performance (VASP) and SICSC (Pearson's correlation coefficient = 0.696; P = 0.001) suggested moderate convergent validity. The correlation between total score of VASP and GHQ-12 (Pearson's correlation coefficient = -0.046; P = 0.648) implied good divergent validity. CONCLUSION: VASP seems to be a promising scale to assess social performance in people with mental illness.

Insight in psychosis: A critical review of the contemporary confusion.

This commentary highlights the context, complexity, conflicting claims and the contemporary confusion related to insight in people with psychosis. Traditional psychiatric precepts suggests that good insight is inversely related to the severity of psychotic symptoms and directly related to depression scores, better clinical outcome, and treatment adherence. However, recent studies have recognised that insight does not predict outcomes, changes over time, and is dependent on the trajectory of the individual's illness and the social and cultural context arguing that "insight" is an explanatory model and a coping strategy. Methodological issues related to the assessment of insight, the limitations of psychiatric classification and complex interaction between biology and the environment make simplistic explanations of the concept of insight less than useful. The paper argues that the biomedical model should be presented without dismissing or devaluing patient beliefs and explanations. Psychiatry needs to embrace the complexity of mental illness and value diverse attempts at restoring homeostasis.

A Qualitative Study Exploring the Lived Experience of Unemployment Among People with Severe Mental Illness.

BACKGROUND: Severe mental illnesses lead to deterioration in the life skills of the patient, resulting in socio-occupational dysfunction and low rates of employment. The purpose of this study was to explore attitudes, knowledge, and barriers to employment as experienced by patients and their caregivers in India. METHOD: Patients with schizophrenia or bipolar affective disorder, aged between 18 and 60 and undergoing inpatient treatment and their caregivers, were approached for written informed consent and recruited for focus group discussions. A total of eight focus groups were conducted until saturation of themes was seen to have been achieved. The data were transcribed, coded, synthesized, and organized into major findings and implications for practice. RESULTS: Role expectations based on gender were seen to influence the decision to work. The possible recurrence of illness due to excess stress and unsupportive working environments was cited as the most common problem that could arise related to employment. Stigma and faulty attributions related to the illness were the most cited barriers to employment. Most participants felt that psychosocial rehabilitation and family and community support were essential for facilitating work. Most participants did not consider mental illness as a disability and were unaware of government schemes for the mentally ill. CONCLUSION: Considering gender-based role expectations, avenues for self/family employment and improving the awareness of benefits for mental illness both among consumers and health care professionals are essential to enhance economic productivity in people with severe mental illness.

Idioms of distress, mental symptoms, syndromes, disorders and transdiagnostic approaches.

Euro-American idioms of distress and their corresponding symptom clusters have been universalised as mental disorders and are now the gold standard for psychiatric diagnosis around the globe. This paper discusses issues related to mental disorder diagnosis from a cultural perspective. It argues that psychiatric diagnoses, while having good inter-rater reliability, lack external validity. It contends that psychiatric categories and labels are supported by the current political economy of health. Nevertheless, it suggests that (i) all symptoms have a metaphoricity to convey a variety of distress, (ii) idioms are polysemious and have a capacity for multiple meaning and pragmatic implications, beyond local and cultural inferences, (iii) idioms of distress are performative, are a form of social action that effects social change, and are prone to improvisation of expression that is associated with adoption in new and changing contexts, (iv) psychiatric idioms are as easily accepted as local and folk beliefs and expressions, (v) idioms of distress are used for negotiating access to care, cure and healing across regions and cultures. The paper argues that new (psychiatric) idioms are easily adopted across regions and societies, and that they eventually change contexts and cultures.

Sexual Dysfunction in Drug-Naïve or Drug-Free Male Patients with Psychosis: Prevalence and Risk Factors.

BACKGROUND: There is a growing body of literature on the high prevalence of sexual dysfunction in patients with psychotic disorders. However, most studies have focused on medication-related sexual side effects. MATERIAL AND METHODS: Consecutive males with a diagnosis of acute psychosis or schizophrenia who were either drug-naïve or drug-free for six months were recruited to the study after obtaining informed consent. Sociodemographic and clinical data, psychopathology (using Positive and Negative Syndrome Scale), and sexual functioning (using The International Index of Erectile Functioning and DSM-IV TR criteria) were assessed. Bivariate and multivariate statistics were obtained. RESULTS: One hundred males were recruited. The overall prevalence of sexual dysfunction by DSM IV-TR criteria in this population was 17%. The factors that were associated with sexual dysfunction were older age and later age of onset of illness. The rate was higher on excluding those who said that they were not sexually active (25%). CONCLUSIONS: Sexual dysfunction may be found in patients with psychotic disorders even prior to commencing antipsychotic medications. It is possible that this is contributed to by several factors including the disease process. Assessment of sexual function in these patients will help in early identification and appropriate management.

"We sold the buffalo to pay for a brain scan" - a qualitative study of rural experiences with private mental healthcare providers in Uttar Pradesh, India.

The majority of persons with mental distress (PWMD) in India do not have access to care, and even those who seek care are pushed to attend private providers, given the weak and largely absent public mental health services framework. The aim of this study was to examine the experiences in help-seeking and with unethical health service provision among persons with mental distress in the Saharanpur and Bijnor districts of Uttar Pradesh. In-depth interviews were conducted with twenty persons with mental distress and their caregivers. Thematic analysis yielded four key findings about help-seeking: first, that it was syncretic and persistent; second, that expenditure for private care was high and often catastrophic; third, that investigations and care provided were pharmacological and predominantly irrational and excessive; and lastly, that help-seeking was abandoned. This study demonstrates that PWMD are particularly vulnerable to exploitation by private providers with illnesses that are stigmatising, poorly understood, chronic, relapsing, and disabling and that often require complex management. Responding to mental distress requires multiple empowering and interacting policy and programme initiatives that must include regulation of private and public providers, resources, and actions to strengthen public and primary mental healthcare and promotion of mental health competence in communities.

Knowledge and Attitudes toward Sexual Health and Common Sexual Practices among College Students - A Survey from Vellore, Tamil Nadu, India.

BACKGROUND: Indian society is considered to have conservative attitudes regarding sex and is ambivalent about the concept of sex education. Previous reports suggest that a considerable proportion of Indian youth have inadequate sexual knowledge and hold a variety of sexual misconceptions. Methodological flaws limit the generalizability of some earlier studies. AIMS: This study assessed knowledge and attitude toward sexual health and common sexual practices among college students in Tamil Nadu. METHODOLOGY: A total of 952 students from seven randomly selected colleges in Vellore district of Tamil Nadu participated in the survey. The survey questionnaire contained 51 questions on knowledge and attitude toward sexual health and common sexual practices and incorporated items from standardized questionnaires and additional questions suggested by a multidisciplinary group who work in the field. RESULTS: Two hundred seventy-five students among those who completed the survey were women. Higher knowledge scores were associated with older age, male gender, being from a rural background, pursuing non-science streams, and being in postgraduate courses. Nonconservative attitudes were associated with older age, male gender, enrollment in non-science disciplines, discomfort with the family environment, and a religious family background. CONCLUSIONS: Sexual knowledge is inadequate and sexual misconceptions were widely prevalent in the population studied. School-based comprehensive sex education programs, which have been demonstrated to be effective in improving sexual health, could be used to deal with these lacunae in sexual health knowledge and attitudes.

Sexual Dysfunction among Men in Rural Tamil Nadu: Nature, Prevalence, Clinical Features, and Explanatory Models.

BACKGROUND AND AIM: There is a dearth of community data on nature, prevalence, clinical features, and explanatory models related to sexual dysfunction among men, particularly from rural India. This study attempted to examine different aspects of male sexual dysfunction and misconceptions in the community. MATERIALS AND METHODS: Villages in Kaniyambadi Block, Vellore district were stratified, and four were randomly selected. Men living in these villages were recruited for the study. The following instruments were administered: (i) International Index of Erectile Function, (ii) Chinese Index of Premature Ejaculation (iii) Short Explanatory Model Interview, and (iv) Revised Clinical Interview Schedule. The data were analyzed using standard bivariate and multivariate statistics. RESULTS: A total of 211 men were recruited. The majority were middle-aged (mean 40.73 years), literate (84.8%), married, and with children (72%), from nuclear families (99.6%), followed the Hindu religion (87.7%), reported satisfaction with their marriage (51.2%), had a single sexual partner (99.5%), and practised contraception (88.2%). A minority reported erectile dysfunction (29.9%), premature ejaculation (19.4%), and depression/anxiety (30.8%). Erectile dysfunction was associated with single marital status (P < 0.001), premature ejaculation (P < 0.001), worry about nocturnal emission and loss of semen (P < 0.02), and punishment by God as causal beliefs (P < 0.001). Premature ejaculation was associated with diabetes mellitus (P < 0.05), alcohol use (P < 0.05), anxiety and depression (P < 0.01), guilt about masturbation (P < 0.001), and belief that nocturnal emission is causal (P < 0.001) and erectile dysfunction (P < 0.05). CONCLUSION: Sexual misconception and dysfunction in men are significant problems in rural communities in India. They mandate the need for sex education in schools and the empowerment of physicians in primary and secondary care to manage such problems.

Mild cognitive impairment and dementia in older patients attending a general hospital in south India: DSM-5 standards and correlates.

ABSTRACTBackground and Aims:The changes in DSM-5 diagnostic criteria for dementia (Major neurocognitive disorder (NCD)) and mild cognitive impairment (mild NCD) mandate a re-evaluation of screening instruments. This study attempted to validate screening instruments, identify optimum threshold, and describe their indices of efficacy. METHOD: Consecutive people above the age of 65 years attending the outpatient department of a general hospital were recruited. They were assessed using the Mini-Mental State Examination and the Vellore Screening Instruments for Dementia and were evaluated against the DSM-5 standard. Bivariate and multivariate statistics were obtained. Receiver-operating-characteristic curves were drawn, optimum thresholds obtained, sensitivity, specificity, and predictive values calculated. RESULTS: One hundred and thirty four older people were recruited. The majority were women, married, with low levels of education, not employed, living with family, and had medical co-morbidity. A minority satisfied DSM-5 criteria for major (1.5%) and mild NCD (36.5%). The factors associated with NCD were older age, fewer years of education, and lower socio-economic status. MMSE, VSID patient, and VSID informant scores were significantly associated with NCD. The indices of efficacy for the MMSE and VSID patient version were modest for identifying Mild NCD. However, their performance in identifying major NCD was better. Nevertheless, optimal thresholds for recognition differed markedly from their originally recommended cut-offs. CONCLUSIONS: The DSM-5 standards, with new and different cognitive domains, mandate a revaluation and recalibration of existing screening instruments. Ideally, new screening instruments, which match the cognitive domains and DSM-5 standard should be developed.