A summary of epidemiological studies in psychiatry conducted in India

1. Epidemiological studies in
psychiatry in India

2. • Epidemiology is concerned
with
• Understanding and
controlling disease
epidemics by investigating
empirically the associations
between agent – host –
environment
Agent
HostEnvironment

3. Psychiatric Epidemiology
• Psychiatric epidemiology lags behind than other branches of
epidemiology due to
• Difficulties encountered in conceptualizing
• Difficulty in diagnosing
• Difficulty in defining a case
• Difficulty in sampling
• Difficulty in selecting an instrument
• Lack of resources
• Stigma

4. Epidemiological research in Psychiatry: Indian
scene
• Journey started six decades back (1950-60)
• First psychiatric epidemiological study in India: 1961, Agra By Dr.K. C.
Dube
• Development of PSE
• Development of Indian Psychiatric Survey Schedule (IPSS)

5. Initial epidemiological studies in India
• Prevalence of psychiatric disorders
• 9.5 to 370 per 1000 population
• Limitation: Wide variation in the prevalence rates

6. Landmark International epidemiological
studies
• Epidemiological Catchment Area Program
• National comorbidity Survey
Wide
variation in
prevalence
rates

8. Pitfalls in Indian studies
• Indian epidemiological studies were largely inadequate to tap
• Non-psychotic disorders like panic disorder, social phobia, obsessive
compulsive disorder, sexual dysfunction, substance use

9. Drugs use (prevalence) in general population
among males (Percent)

10. Substance use disorder
http://www.who.int/substance_abuse/publications/atlas_report/profiles/india.pdf

11. Epidemiological studies in substance use
disorder
• National Household Survey (NHS)
• Drug Abuse Monitoring System (DAMS)
• Rapid Assessment Survey (RAS)
• Focussed Thematic Studies (FTS)
• Drug abuse and women in India
• Burden on women through abusing family members
• Drug abuse in rural population
• Drug consumption in border areas
• Drug abuse in prisons
http://www.unodc.org/pdf/india/presentations/india_national_survey_2004.pdf

12. National Household Survey (NHS)
• Sponsored by the Ministry of Social Justice and Empowerment
(Government of India) and the United Nations Office of Drugs and
Crime (UNODC)
• Sample Size: 40,697 males (12-60 yrs)
• Prevalence of ‘current’ use (i.e., during last month)
„Alcohol: 21%
„Cannabis: 3%
„Opiates: 0.7%
 „(heroin 0.2%)
„Any illicit drug: 3.6% (excl. tobacco and alcohol)
„IDUs (‘ever’): 0.1%
„22.3% are poly-drug users
http://www.unodc.org/pdf/india/presentations/india_national_survey_2004.pdf

13. Drug Abuse Monitoring System (DAMS)
• Drugs used
• Alcohol: 44%
• Stimulants (ATS): 2%
• Opiates: 26%
• Others: 16%
• Cannabis: 12%
• IDU (ever): 14%
• Onset of use: 21-30 yrs (46%)
http://www.unodc.org/pdf/india/presentations/india_national_survey_2004.pdf

14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146212/

15. • IPSS
• International Pilot Study of Schizophrenia
• Conducted by WHO
• 9 countries (5 developed & 4 developing)
• Indian center - Agra
• Aim: Feasibility in conducting F/U study
• Assessment: Baseline, 2yr, 5yr
• Drop out at 5yr: 24%
• Conclusion: Outcome of Schizophrenia better in
developing countries than developed countries

16. DOSMeD
• Determinants of Outcome of Severe Mental
Disorders
• Conducted by WHO
• 12 centers in 10 countries
• Indian centers – Agra & Chandigarh (rur/urb)
• Aim: Prevalence of Schiz & outcome
• Follow up: 2 years (80%)
• Conclusion: Developing countries had better
outcome. Indian population – less time spent in
psychotic episode & less impairment of social
functioning

17. ISoS
• International Study of Schizophrenia
• Conducted by WHO
• Follow up of cohorts from DOSMeD and RAPyD
(Assessment & Reduction of Psychiatric Disability)
• Cohorts – Incidence cohorts & Prevalence cohorts
• Incidence cohorts – 12 from DOSMeD & RAPyD,
Hong Kong , Madras
• Prevalence cohorts- 3 from IPSS, Beijing
• ICD-8 , 9 diagnoses were converted to ICD-10

18. ISoS
• 3 groups (Schizophrenia only – F20; other psychotic
disorders- F10.5, F22 to 29, F30 to 34; total
psychosis)
• PSE-9, DAS, GAF, SANS, Psychological Impairment
Schedule used
• Conclusion: Outcome of schizophrenia is poorest.
No independent role of type of onset. Percentage
of time spent in experiencing psychotic symptoms
in the first 2 years of onset was the best predictor
of outcome.

19. • ICMR
• Conducted by ICMR
• Centers: Vellore, Madras, Lucknow
• Aim: Course & outcome of F20
• Modified criteria for Schizophrenia used (Modified
Feighner et al.)~ duration 3mon. instead of 6mon.
• Follow up period – 2 years
• Follow up rate- Madras 86%, Lucknow 85%,
Vellore 76%
• Conclusion: Best pattern of course in 45%, worst
pattern 10%. Confirmed the findings of IPSS,
DOSMeD

20. • IPSS Agra Cohort
• Long term follow up
• Aim: Long term Course & outcome of F20
• The cohort was followed up upto 14 years (KC
Dube and team)
• Conclusion: Illness tends to lose its intensity with
passage of time
• Limitation: High attrition rate

21. • Madras longitudinal study
• Long term follow up (10 years)
• Aim: Long term Course & outcome of F20
• The ICMR cohort was followed up upto 10 years
(Thara et al.)
• Conclusion: Clinical and social outcomes are
better than developed countries

22. Grover S, Avasthi A, Gupta S, Dan
A, Neogi R, Behere PB, Lakdawala
B, Tripathi A, Chakraborty K, Sinha
V, Bhatia MS, Pattojoshi A, Rao TS,
Rozatkar A. Comorbidity
in Patients with Dhat
Syndrome: A
Nationwide
Multicentric Study.J
Sex Med. 2015 Apr 22.
32.8% - No comorbidity
20.5% - Depressive disorders
20.5% - Neurotic, stress-related and
somatoform disorders
Half (51.3%) of the study sample had
comorbid sexual dysfunction.

23. Children and adolescents
• Prevalence of Psychiatric disorders
– 0.48% to 29.40%
– Non-representative sample
– Small sample
– Non-standard criteria
– High drop out rate after screening

24. Children and adolescents

25. National Mental Health Survey
• National Mental Health Survey (NMHS)
is the largest nationwide survey on
Mental health in India.
• Funded by the Ministry of Health and
Family Welfare, Government of India.
• Conducted in 12 states of the country
• National coordinating center: National
Institute of Mental Health and Neuro
Sciences (NIMHANS), Bangalore, is the
coordinating centre for this survey.

26. National Mental Health Survey
• Objectives:
– Estimate the burden of mental health
problems
– Identify the gap in human resources &
services for mental health in the
country

27. Tools used
• M.I.N.I 6.0
• M.I.N.I –Kid 6.0
• Questionnaire for Tobacco, Epilepsy, Autism, Intellectual
Disability
• Questionnaire for disability (SDS), Help-seeking behavior &
cost of treatment

28. Prevalence
of mental
disorders

29. Prevalence of common and severe mental
disorders

30. Prevalence of psychoactive substance use

31. Prevalence of psychoactive substance use

32. Prevalence of mental disorders (%) in
adolescents

33. Adolescents
• Overall prevalence of mental health morbidity: 7.3%
• Common mental disorders- 5.4%
• Severe Mental Disorders – 1.4% (life time)
• Autism – 1.6% (screener positive)
• CD, ODD, ADHD- 0.8%

34. Prevalence of mental disorder in different
States (%)

35. Prevalence of epilepsy and intellectual disability
• Under NMHS, epilepsy and intellectual disability was identified using
the screener instrument.
• The prevalence of epilepsy (Generalized Tonic Clonic Seizures) was
0.3%, with nearly 2 million persons requiring care.
• The prevalence of intellectual disability was 0.6% in the surveyed
population, resulting in nearly 4 million persons requiring care.

36. Treatment Gap for different mental disorders
(%)

37. Treatment Gap for different mental disorders
(%)
• Mental health problems (except substance use)- 84.5%
• Common mental disorder – 85%
• Severe mental disorder – 73.6%
• Substance Use disorder – 91.1%
• Alcohol – 86.3%
• Tobacco – 91.8%
• Other – 72.9%
• Epilepsy – 31.3%
• ID- 70.5%

38. Mental Health specialist human resources in
NMHS States (per lakh population)

39. NATIONAL SURVEY ON EXTENT AND PATTERN OF
SUBSTANCE USE IN INDIA
(NATIONAL DRUG USE SURVEY)
• A large-scale epidemiological study being conducted across the
country to estimate the prevalence of use of various psychoactive
substances in the Indian population.
• Objectives:
• (i) To provide state- level estimates of proportion and absolute number
of people who use various substances and people who are suffering from
substance use disorders in India.
• (ii) To map the presence of service and intervention for individual
suffering from substance use disorders and identify the gaps in service
delivery.

40. NATIONAL SURVEY ON EXTENT AND PATTERN OF
SUBSTANCE USE IN INDIA
(NATIONAL DRUG USE SURVEY)
• The survey has been commissioned and funded by the Ministry of
Social Justice and Empowerment (MoSJE), Government of India
which is the nodal ministry on Drug Demand Reduction.
• The Ministry of Social Justice and Empowerment has designated
National Drug Dependence Treatment Centre (NDDTC) , All India
Institute of Medical Sciences (AIIMS), New Delhi as the nodal agency
for conducting the survey.

41. NATIONAL SURVEY ON EXTENT AND PATTERN OF
SUBSTANCE USE IN INDIA
(NATIONAL DRUG USE SURVEY)
• NDUS involves a combination of several methodological approaches
to study the drug use situation in the country which include
• A general population survey in a representative sample of households
throughout India
• A Respondent Driven Sampling Survey
• Focussed thematic studies and survey among service providers

42. Implications
• Relevance of epidemiological studies
• Why
• What
• How
• Who
• Whom

43. Suggested readings
• Psychiatric epidemiology in India. Indian J Med Res 126, September 2007, pp 183-192
http://icmr.nic.in/ijmr/2007/september/0903.pdf
• Psychiatric epidemiology: selected recent advances and future directions
http://www.who.int/bulletin/archives/78(4)464.pdf
• Indian Psychiatric epidemiological studies: Learning from the past
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146182/
• Prevalence of child and adolescent psychiatric disorders in India: a systematic review and
meta-analysis https://capmh.biomedcentral.com/articles/10.1186/1753-2000-8-22
• National Mental Health Survey http://indianmhs.nimhans.ac.in/results/nmhs.html#close
http://indianmhs.nimhans.ac.in/publications/reports-2016.html
• National Drug Use Survey
http://www.ndusindia.in/about-us.html
http://www.ndusindia.in/survey/Rationale-NDUS.html