Вы находитесь на странице: 1из 8

APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.

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 mentally ill in the rural areas.


Curative efforts have usually remained the According to Kulhara 2 , nearly 300,000 and
focus in the post independence era of mental health 105,000 cases of schizophrenia are added every year
services in India. Although scanty efforts have been in rural and urban population respectively. Out of
made in the area of psycho-social rehabilitation; these 40-60% cases go through the phase of chronic
which is now becoming a priority area day by day and suffer impairment and disabilities. Thus it is
due to increasing population of severely mentally evident that roughly 150,000 or more people
ill in the country. Agarwal’s 1 apt remark ‘our suffering from schizophrenia are added every year
forgotten millions’ about severely mentally ill of to the country’s post of disabled schizophrenic
the country signifies that we have paid more population.
attention only to treatment and really forgotten the Extent of the problem
severely mentally sick persons of the country.
The prevalence of schizophrenia varies from
Kulhara2 felt that this population has remained a
2-3/1000 all over the world. Indian researchers have
neglected lot and now active action oriented efforts
also reported similar rates ranging from 0.9 to 4.3/
are needed to manage and rehabilitate this neglected
10004-6 Wig et al.7 noted an incidence of 4.47/10,000
population. Kapur 3 advocated need for suitable
in rural area and 3.8/10,000 in urban area. Above
assistance to the families of managing severely
Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society 109
DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010

figures give an estimate that there will be sample of the study. Patients were divided into
approximately 2 million persons suffering from experimental and control group alternating one
schizophrenia at any given point of time. another in sequential manner. Patients with
Affective disorders are now conceptualized as diagnosis of chronic psychosis more than two years
chronic illnesses and the earlier notion of a better with age range between twenty and forty years, can
prognosis is being replaced with the acceptance of follow simple instructions and on maintenance
the fact that very few patients of affective disorder medication were included. Patients with co
have a single episode, majority have relapsing morbidity or neurological/ physical illness, having
course and 10-20% have chronic course.8 Overall severe side effects of medicines and score on Mini
lifetime prevalence for major depression has been Mental State Examination less than twenty were
found around 5%. The prevalence rates of manic excluded.
depressive psychosis are reported to be 1.3/1000.5
Tools
Disability arising out of severe mental illness
is defined as an inability to perform at a serially Demographic Data Sheet: A data sheet was
desirable level in such activities i.e. self are, social devised which included the details of the subject’s
relationship, work and situational appropriate age, sex, education, occupation, marital status, onset
behavior. of illness, total duration of illness with exacerbation
Aggarwal1 outlined that roughly 0.5% to 1% of symptoms, current medication and side effects
population will have certain disability due to etc.
chronic mental illness; barring a few thousand all Mini Mental State Examination (MMSE)17,
others are living in the community. Indian MMSE has been used as a screening tool. A score
researches in the area of psycho-social intervention less than 20 (maximum score- 30) signifies poor
based rehabilitation of people suffering from mental cognitive functions as they were not able to follow
illness have covered sociological and psychological even simple instructions.
characteristics of chronic psychiatric population,8 Positive and Negative Syndrome Scale
treatment needs of chronic psychiatric patients, (PANSS)18, PANSS is a seven point rating scale
attrition in follow up of schizophrenic10 nature and ranging from absence of symptom to presence of
course of disability11-12 care givers burden and symptom in terms of its severity. This shows the
coping13,14 family burden and it’s assessment15,16 current picture (within one week) of client’s
Padmawati el al, 1985. psychopathology. The scale was used in the study
Present study was formulated to assess the to see the impact of intervention strategies on
rehabilitation needs and effect of intervention on symptom reduction.
severely mentally ill population, counseling dearth Rehabilitation Needs Assessment Schedule
of intervention based studies in the Indian context. (RNAS) 19 , RNAS covered the: Employment,
Vocational training/guidance, Accommodation,
Methods Leisure activities, Psychosocial attitudes
Aim of the present study was to find out the modification, Skills training, any help needed by
rehabilitation needs including family burden of the family areas. RNAS collects quantitative
chronic mentally ill and to study the effect of information on the subjective needs of the client.
intervention. Out of total eight items, two items (item 6 and 7)
are addressed to key informant, rest all other items
Sample
are asked from the client.
Chronic mental patients under treatment and The Schedule for Assessment of Psychiatric
regular follow ups of out-patient or indoor clinics Disability (SAPD), 15 The instrument is the
of Institute of Human Behaviour and Allied modified version of Disability Assessment Schedule
Sciences (IHBAS), Delhi, were the universe of the (II) of WHO to make this applicable to the existing
study. Total 50 consecutive patients identified socio-cultural norms in India. Inter rater reliability
within a period of three months, who fulfilled the carried out for every third case was noted to be 0.92
inclusion and exclusion criteria, were selected as (Kappa index). Items of this tool are rated by
110 Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society
APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1

interviewing the caregivers of the subjects, Statistical analysis of the data was done using
considering their functioning over the past one descriptive statistics.
month. Higher scores signify greater degree of Intervention Strategies
disability.
Intervention strategies used in this study were:
Dysfunction Analysis Questionnaire
Psycho-education, Activity Scheduling, and Skills
(DAQ),20 DAQ assesses deterioration/dysfunction
training including social skills, pre-vocational and
due to illness in social, family, personal, vocational
vocational training. (Details of intervention are
and cognitive areas. Clients are rated on this
available with the first author).
instrument with the help of caregivers rating is done
for each area-wise (10 items in one area; total 50 Results
items) on a five point scale. A higher score on this Results are presented in tables 1 to 7.
questionnaire shows greater degree of dysfunction.
Subjective Well Being Inventory (SUBI)21 Table-1. Indicates the Demographic
SUBI was developed by WHO considering a characteristics of the identified sample
priority area which needs to be studied thoroughly. Demographic Experimental Control
SUBI explores subjective well being as an indicator Characteristics group Group
of quality of life including the perceived quality of (n = 25) (n = 25)
social networks. Hindi version of this inventory was Age (mean & SD 29.90 ± 6.07 31.50 ± 8.12
made available by Nagpal.21 Higher scores signify in years)
Age range 21 to 39 20 to 38
low degree of subjective well being and quality of Male 23 15
life. This inventory is filled up by the client himself Female 02 10
being a self report of well being. Education (in years of 12.40 ± 2.26 11.52 ± 3.17
schooling)
Procedure Marital Status
Referred cases from the Department of Single 22 17
Married 01 06
Psychiatry were included in the study as per Separated 02 02
inclusion and exclusion criteria. Initial screening Occupation
of all the referred clients was done with the help of Housewife 02 03
socio-demographic data sheet and MMSE. Subjects Unemployed 23 22
Duration of illness 9.09 ± 6.70 11.21 ± 6.67
and their caregivers were explained the purpose of
this study and their written consent was obtained Table-2. Assessed rehabilitation needs of the
to participate in the study. Subjects were allotted studied subjects in both the groups
to groups alternatively to form two groups:
Rehabilitation Needs %
experimental and control of 25 subjects in each Social skills 80
group. Pre-assessment for all the subjects was done Employment 65
within one week of their enrolments as per Providing help for families 60
requirement and availability of caregivers either in Leisure activities 45
Vocational training 30
IHBAS or at their native locations in the family.
Modifying psychological environment 25
For the experimental group initial assessment
was followed by intervention, which commenced Discussion
with psycho-education for the family and the In the initial phase of the study rehabilitation
subjects. Social skills training introduced sub- needs were identified. Assessment of rehabilitation
sequently, varied from subject to subject according needs indicated that social skills training was the
to their needs and deficits. After completion of most preferred area of intervention (Table 2) by
intervention for 3 months post term assessment was 80% of subjects of both the groups (Experimental
done for both the groups. Control group was wait- and Control), followed by employment (65%),
listed for the purpose of this research. Intervention providing help for families (60%), leisure activities
training was extended to them after completion of (45%), vocational training (30%) and modification
post assessment, i.e. after twelve weeks. of psychological environment (25%).
Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society 111
DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010

Table 3 Pre and post assessment mean scores of both the groups on MMSE
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 25.40 28.04 25.08 24.70 28.04 24.70


S.D. 1.68 1.27 2.12 1.90 1.27 1.90

t 7.39** 1.13 7.24**

** Significant at .01 level

Table 4 Pre and post assessment mean scores of both the groups on PANSS
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 8.08 1.12 7.60 7.96 1.12 7.96


SD 4.48 1.09 5.63 6.23 1.09 6.23

t 7.36** 0.33 2.18**

** Significant at .01 level * Significant at .05 level

Table 5 Pre and post assessment mean scores of both the groups in SAPD
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 17.76 8.40 17.80 20.88 8.40 20.88


SD 6.14 4.90 6.31 6.54 4.90 6.54

t 12.41** 3.66 7.61**

** Significant at .01 level

Table 6.1 Pre and post assessment mean scores of both the groups on DAQ: SOCIAL
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 37.60 21.32 42.92 42.08 21.32 42.08


SD 7.19 6.14 5.76 5.26 6.14 5.56

t 8.23** 0.71 12.81**

** Significant at .01 level

Table 6.2 Pre & post assessment scores of both the groups on DAQ: VOCATIONAL
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 44.44 42.60 42.52 43.48 42.60 43.08


SD 5.90 6.03 5.65 4.87 6.03 4.87

t 1.49 0.73 0.23


112 Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society
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
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 40.00 18.84 41.04 40.48 18.84 40.48


SD 8.73 9.17 8.69 8.07 9.17 8.07

t 6.99** 0.69 8.03**

** Significant at .01 level

Table 6.4 Pre and post assessment mean scores of both the groups on DAQ: FAMILY
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 42.00 19.80 43.24 40.16 19.80 40.16


SD 6.95 6.05 7.56 8.69 6.05 8.69

t 13.39** 1.93 9.60**

** Significant at .01 level

Table 6.5 Pre & post assessment mean scores of both the groups on DAQ: COGNITIVE
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 38.08 18.84 40.00 39.92 18.84 39.92


SD 7.98 6.68 7.78 8.18 6.68 8.18

t 12.34** 1.29 10.04**

** Significant at .01 level

Table 7 Pre and post assessment mean scores of both the groups on SUBI
Experimental group Control group Experimental group Control
N=25 N=25

Pre Post Pre Post Post Post

Mean 8.24 5.28 7.96 8.68 5.28 8.68


SD 1.12 1.47 1.13 0.79 1.47 0.79

t 9.26** 3.83 10.80**

** Significant at .01 level


These needs have been classified into four Observations based on Mini Mental State
categories being critical to effective functioning i.e., Examination in the pre-post (experimental group
symptom reduction including disability remedia- only) and Post (experimental and control) sessions
tion, skill development, social support enhancement were suggestive of positive effect of intervention
and environmental adaptation. Effective service on cognitive functions (Table 3) of the subjects of
delivery to meet these needs is determined by experimental group. They differed significantly
client’s assessment, client’s education, professional from their control counterparts. Menon22 stressed
competencies and outcome evaluation. the role of intervention and its positive effect on
Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society 113
DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010

cognitive remediation. George et al23 also observed to long duration of chronic mental illness of the
that predominant negative symptoms were subjects. Further, training in the prevocational or
responsible for deficits in chronic schizophrenic vocational skills were not well structured at the time
clients. Improvement in cognitive functions is of this study in day care centre of IHBAS. Hence,
evident as a result of symptom reduction. Pradhan the same was not included in the intervention
et al24 and Chaddha et al25 noted that symptomatic package of this study. These findings of Dysfunction
recovery is usually better and easily achieved than analysis supported our earlier observations related
functional recovery. They emphasized the role of to personal and social skills, disability assessment
psycho-social rehabilitation to achieve functional (Table 5) and improvement in cognitive functions
recovery. Jones26 stated that cognitive impairment (Table 2 & 4). Family area of dysfunction analysis
combined with competency screening can be used was important3 as DAQ was filled up with the help
successfully to identify patients at risk for poor of caregivers, who rated their sick family member’s
functional status. Change noted here in the cognitive dysfunction level in the family. In the post
status of the experimental group of subjects as a assessment sessions after completion of
result of exposure to psycho-education, activity intervention significant change in rating was noted.
scheduling and social skills training is indicative Scores of experimental and control group in Pre-
of the fact that intervention helps in improving the post and Post-post sessions differed significantly
cognitive functions of the chronic mentally ill (Table 6.4) which suggests that psycho social
persons. Subsequently, significant difference intervention was helpful in changing the perception
between the scores (Table 4) obtained on Positive of caregivers who considered them dysfunctional
and Negative Symptom Scale by experimental and or burden in the family.
control group in Pre-Post and Post-Post assessments Subjective well being explored in this study
further validates the observation that intervention (Table7) as an indicator of Quality of Life has
given was helpful in symptom reduction. Disability shown favourable results. Scores obtained on
remediation with the help of skill training. 22,27,28 Subjective Well Being Inventory by experimental
Results based on assessment of psychiatric disabi- group in the pre-post and post-post assessments
lity were in conformity with observation made by indicate positive change in subjective well being
these authors. Pre-post and post-post assessment (as a measure of Quality of life) of experimental
scores of experimental group indicated significant group subjects. Regarding intervention package
decrease in psychiatric disability. Findings further used in this study, it was observed that psycho-
suggested that contr ol group deprived of education used with subjects and their family was
intervention scored higher on disability scale and helpful in changing the perception of family towards
showing increase in psychiatric disability (Table their sick family members (Table 6.4) and also in
5). These observations suggest that interventions decreasing perceived family burden.
of psycho-social nature play an important role in Activity scheduling and social skill training
minimizing psychiatric disability of chronic were proved to be useful in improving cognitive
mentally ill. Thara and Srinivasan15 reported similar function, disability remediation, psychopathology
results based on their study. and quality of life in the subjects of experimental
Dysfunction in the area of social, vocation, group.
personal, family and cognitive caused by chronic
Limitations of the study
mental illness (Table 6.1 to 6.5) was analyzed in
this study with the help of Dysfunction Analysis Although family (care givers) was focused in
Questionnaire. This analysis also focused on the study, as they were included in the need
assessing the improvement, which has taken place assessment and intervention through Psycho-
as the result of intervention given. There was education programme and intervention package to
significant positive change in all the aforesaid areas address and meet their needs, effects of intervention
as seen in the scores of experimental group except in terms of acquired skills, measured in the pre and
in the vocational area. This may be due to less or post assessment sessions were confined to day care
no involvement of the subjects in any vocation due centre and IHBAS only. Their replication was not
114 Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society
APRIL 2010 DELHI PSYCHIATRY JOURNAL Vol. 13 No.1

followed up in the family or community setting due 7. Wig NN, Varma VK, Mattoo SK, Behre PB,
to limitation of and non availability of time. Phookan HR, Misra AK, Sriniwasmurthy R,
Family visits made during this research work Tripathi BM, Menon DK, Khandelwal SK, Bedi
only intended to get rating of caregivers in different H. An incidence study of schizophrenia. Indian
areas of rehabilitation need assessment and J Psychiatry 1993; 35(1) : 11-17.
intervention services introduced. Structured 8. Stephens JH. Long term prognosis and follow
education for the family was conducted mostly in up. Schizoph Bull 1978; 1(4) : 25-47.
day care centre of IHBAS, Delhi only. 9. Chadda RK, Pradhan SC, Bapna JS, Singhal
R. Treatment needs of Chronic Psychiatric
Conclusion
patients. J Mental Health Human Behav 2000;
Severe chronic mental illness, which causes 5(1) : 13-18.
disability in the personal, family and social living 10. Thara R, Rajkumar S, Valecha V. Schedule for
of victim, is increasing day by day in the country. the assessment of Psychiatric disability-a
Hence, utmost attention is needed to cater to the modification of the DAS-II. Indian J Psychiatry
rehabilitation needs of this population. Management 1988; 30(1) : 97-102.
of these clients largely based on use of medicines 11. Thara R, Rajkumar S. A study of sample
to manage symptoms. Psychosocial intervention attrition in follows up of schizophrenia. Indian
using psycho-education; activity scheduling and J Psychiatry 1970; 32(3) : 217-222.
social skill training was noted to be effective in 12. Thara R, Rajkumar S. Nature and course of
symptom reduction, disability r emediation, disability in schizophrenia. Indian J Psychiatry
improving subjective well being, cognitive ability 1993; 35(1) : 33-35.
and function in personal, social and family areas. 13. Walia A, Singh TB, Shivalkar R. Hospital based
Psycho-social model of rehabilitative effort to help cross sectional study of caregivers burden in
clients suffering from chronic mental illness, used chronic schizophrenia. Unpublished M.Phil.
in the study is replicable elsewhere especially in dissertation submitted to University of Delhi,
Day care centers, Psychiatric treatment centers and 2006; Delhi.
other such institutional agencies. 14. Chadda RK, Singh TB, Ganguly KK.
References Caregivers burden and coping: a prospective
study of relationship between burden and
1. Agrawal AK. The forgotten millions. Indian J coping in caregivers of patients with schizo-
Psychiatry 1998; 40 : 103-19. phrenia and biopolar affective disorder. Social
2. Kulhara P. Schizophrenia – the neglected lot: Psychiatry Epidemiology 2007; 42(4) : 923-
Call for action. J Mental Health Human Beh 930.
1997; 2(1) : 3-7. 15. Thara R, Srinivasan L. Management of social
3. Kapur RL. The family and schizophrenia: disabilities in schizophrenia. Indian J
Priority areas for intervention research in India. Psychiatry 1998; 40(4) : 331-337.
Indian J Psychiatry 1992; 35(1) : 3-7. 16. Padmawati R, Thara R, Sriniwasan L, Kumar
4. Sethi BB, Gupta SC. An analysis of 2000 S. SCARF Social functioning index. Indian J
private and hospital psychiatric patients. Indian Psychiatry 1995; 37(4) : 161-164.
J Psychiatry 1972, 14 : 197-206. 17. Folstein MF, Rovner BW. Mini Mental State
5. Dubey KC. A study of prevalence and biosocial Examination in Clinical Practice. J Psychiatr
variables in mental illness in a rural and urban Res 1975; 12 : 189-198.
community of Uttar Pradesh, India. Acta 18. Kay SR, Fiszabein A, Opler LA. Positive and
Psychiatrica Scandinavia 1970; 86 : 499-503. negative symptom scale. Schizophr Bull 1987;
6. Nandi DN, Ajmany S, Ganguli H. Banerjee G, 13 : 261.
Boral, GC, Ghosh A. Sarkar S. Psychiatric 19. Nagaswami N, Valecha V, Thara R, Rajkumar
disorders in a rural community in West Bengal: S, Menon S. Rehabilitation Needs of
An epidemiological study. Indian J Psychiatry Schizophrenic Patients: a preliminary report.
1975; 17 : 87 -99.
Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society 115
DELHI PSYCHIATRY JOURNAL Vol. 13 No.1 APRIL 2010

Indian J Psychiatry 1985; 27 : 213-220. 25. Chadda RK, Pradhan SC, Bapna JS, Singhal
20. Peeshad D, Verma SK, Malhotra A, Malhotra R, Singh TB. Chronic psychiatric patients: an
S. Dysfunction Analysis Questionnaire. assessment of treatment and rehabilitation
National Psychological Corporation, Agra related needs. Inter J Rehabi Research 2000;
1985. 23 : 55-58.
21. Nagpal R, Sell H. Subjective Well being. Searo 26. Jones BN, Jayram G, Samuels J, Robinson H.
Regional Health Papers No. 7, World Health Relating competency status to functional status
Organization 1985. at discharge in patients with chronic mental
22. Menon SM. Psycho-social rehabilitation: illness. J Am Acad Psychiatry Law 1998; 26(1):
current trends. NIMHANS J 1996; 14(4) : 295- 49-55.
305. 27. Gopinath PS, Chaturvedi SK. Distressing
23. George RM, Chaturvedi SK, Murali T, behaviour of schizophrenics at home. Acta
Gopinath PS, Rao SL. Cognitive deficits in Psychiatrica Scandinavia 1992; 86 : 185-188.
relation to quality of life in chr onic 28. Liberman RP, Wallace CJ, Blackwell G,
schizophrenics. NIMHANS J 1996; 14 : 1-5. Kipeliwicz A, Vaccaro JV, Mintz J. Skill
24. Pradhan SC, Sinha VK, Singh TB. Psychosocial training versus psychosocial occupational
dysfunctions in patients after recovery from therapy for persons with persistent schizo-
mania and depression. Interna J Rehabi Res phrenia. Am J Psychiatry 1998; 155(8) : 1087-
1999; 22 : 303-309. 1091.

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 Delhi Psychiatry Journal 2010; 13:(1) © Delhi Psychiatric Society

Оценить