Archives of Indian Psychiatry October 2007

Archives of Indian Psychiatry
Official Publication of the Indian Psychiatric Society, Western Zonal Branch

Honorary Editor G. K. Vankar Professor and Head Dept. of Psychiatry B.J. Medical College and Civil Hospital, Ahmedabad-380016. Cell. : 09904160338 Editorial Board R. Srinivasa Murthy E. Mohhandas Vikram Patel Nimesh Desai K. S. Jacob Nilesh Shah Chittaranjan Andrade Bharat Panchal Shekhar Sheshadri Ashok Nagpal Corresponding Members Dinesh Bhugra Stuart Montgomary Afzal Javed Joseph Johar Prakash Masand Andre Joubert Manoj Shah
Board of Directors Editorial Office Laxman Dutt Ward EI I. R. Rajkumar Dept. of Psychiatry, V. G. Vatwe Civil Hospital, S. M. Amin Ahmedabd-380 016. R. C. Maniar E-mail : ipswzjournal@yahoo.co.in Mukesh Jagiwala Phone : 079-65542770 Fax : 079-65542770 Rajendra Hegde K. S. Ayyar Hemangee Dhavle Govind Bang Shubhangi Parkar Kaushik Gupte Distinguished Past Editors Amresh Shrivastava Mrugesh Vaishnav
Journal Committee Rashmin Cholera Parag Shah Ritambhara Mehta Khyati Mehtalia Anuradha Sovani Charle Pinto Yusuf Matchewala Rjaesh Dhume D.M. Dhavle Shivarathnamma Vivek Kirpekar A. S. Kadri
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Official Publication of the Indian Psychiatric Society, Western Zonal Branch
Jitendra Nanawala President
Chairpersons Subcommittees Lata Vaya Awards
Kaushik Gupte Hon. Secretary Ravindra Kamat C.M.E. Mrugesh Vaishnav Vice President Mukesh Jagiiwala Conference Lalit Shah Treasurer Shrikant Deshmukh Legal Cell Shubhangi Parkar Imm. Past President Vipul Sangani Membership Govind Bang Mukesh Jagiwala Representatives of Central Council
Avinash Joshi Mental Health Awareness
Rajesh Dhume Kishor Gujar Ramesh Mankad Vivek Kirpekar Bansi Suwalka Executive Council Mambers
Neena Savant Psychiatric Eduction
Kausor Abbasi Quiz

Contents
In this issue Editorial Management of common psychiatric problems in medical practice the rationale for alternative strategies. Corporal Punishment In Schools : Are We Still In Stone Age? Psychiatric Education The management of common psychiatric problems in medical practice Dr. Jitendra Nanawala, IPS WZ President 2007-08 Presidential Address Suicide: Western India Context Dr. L. P. Shah Oration Child And Law Original Article Depression in Gynecology OPD Wechsler Intelligence Scale for Children, IVth edition (WISC IV) A multi-center study
Official Publication of Indian Psychiatric Society Western Zonal Branch Volume 9 , No.2, October 2007
Sushil Gawande K. S. Jacob
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Param Shukla
K. S. Jacob
14 Jitendra Nanawala 15
P. C. Shastri
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Snehal Goswami G. K. Vankar A. Sovani S. Thatte R. Korde et al. Jahnavi Acharya Yvonne S. Pereira Ashish Srivastava Melvin CSilva Himanshu Sharma Nimisha Desai Khyati Mehtaliya
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Depression and Anxiety Disorder in Primary care Case Report Promethazine induced Neuroleptic Malignant Syndrome in a patient with Bipolar Affective Disorder Conversion Disorder Presenting As Non-Epileptic Seizures : A Case Report Quiz
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In this issue
Management of common psychiatric problems in medical practice the rationale for alternative strategies. The high prevalence of depression in primary care and the low recognition and treatment rates have stimulated the growth of primary care psychiatry. The current approach has been to borrow from academic psychiatry and attempt to adapt it to primary care practice. This has lead to efforts at educating general practitioners, preparing practice guidelines and conducting courses to improve their clinical skills; however this approach has few takers in actual practice. K. S. Jacob discusses various issues relevant to primary care psychiatry. The reality of primary care demands a radically different approach for managing psychiatric problems in primary care. It includes management of common mental disorders without formal diagnosis and use of a single general protocol for management. There is a need to identify such optimal general protocols and to test their efficacy and effectiveness in clinical practice by using randomized controlled trials. Corporal Punishment In Schools: Are We Still In Stone Age? How far from truth is that!! Shukla discusses the sensitive issue of corporal punishment in the schools in his editorial. Physical form of punishment never helps and research is clear that it only makes the problem worse in the long run. Behavioral problems are not uncommon in such children. He discussed various externalizing and Internalizing behaviors problems along with the strategies to overcome corporal punishment in schools. Suicide : Western India Context Suicide is a huge but largely preventable public health problem. Nanawala discusses this topic in his presidential address because of sudden rise in the cases of suicide particularly in the eastern part of Maharashtra. He discussed the rise in the number of deaths due to suicide in the western India . Causes of suicides, educational status of suicide victims, means adopted for committing suicides has been Sushil Gawande, MD Department of Psychiatry NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Digdoh, Nagpur. e-mail : sushil.gawande@rediffmail.com 4
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discussed in detail. He stressed upon the role of mental health professional in detecting mental disorders in suicide victims and interventions to reduce the risk of repeated suicidal behavior. Child Health and LawAccording to WHO child is defined as a young person upto the age of 18 years. Chronological age as a criterion to define child and adolescent can never do justice to these group of population who are growing and has special developmental needs and problems. In India 2.5 million children die every year, accounting for one in five deaths in the world, with girls being 50% more likely to die. The worlds highest number of working children is in India. India has the worlds largest number of sexually abused children. The Constitution of India recognizes the vulnerable position of children and their right to protection. It guarantees in Article 15 special attention to children through necessary and special laws and policies that safeguard their rights. India is signatory to a number of international instruments and declarations pertaining to the rights of children to protection, security and dignity. Dr. Shastri discusses in detail about child protection, abuse, national policies and centrally sponsored integrated child protection scheme in this article. Depression in Gynecology OPD Psychiatric morbidity is significantly associated with gynecological problems. Depressive disorders are among the most commonly found psychiatric morbidities in women attending gynecology OPD but in the developing world, there is under recognition of these conditions. Goswami and Vankar et al studied the frequency and severity of depressive disorders and its association with gynecological risk factors and psychosocial stressors in 507 patients attending gynecology OPD with Brief PRIME-MD PHQ and Hamilton Rating Scale for Depression at Civil Hospital Ahmedabad. This study demonstrated the need for mental health services in a gynecologic setting. By early detection and management of depression, overall reproductive health of women would improve and deaths due to suicide can be prevented.
Archives of Indian Psychiatry 8(2) October 2007

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Editorial
Management of common psychiatric problems in medical practice the rationale for alternative strategies.
K. S. Jacob
Abstract : The high prevalence of depression in primary care, and the low recognition and treatment rates have inspired primary care psychiatry. The present culture of primary care psychiatry, however, borrows heavily from academic psychiatry and attempts to adapt it to the reality of primary care. The compromise is uneasy and difficult to apply in general practice. The reality of primary care, its problems and opportunities demand unique solutions. The strategies suggested are based on the argument that it is difficult to diagnose and to subcategorize clinical presentations of common mental disorders in primary care. It maintains that diagnostic labels are not necessary for management, as the current psychiatric treatments are essentially symptomatic and are delivered across diagnostic categories. It supports the contention that the presentations currently labeled as anxiety, depression or common mental disorders in primary care are illness experiences that do not require disease labels. It makes a case for the provision of support without medicalising the issues. It also suggests that the standards for medical practice should be based on the issues as seen in primary care rather than those used in tertiary and specialist settings. Randomised controlled trials should be used to prove the efficacy and effectiveness of such approaches. Key Words : primary care psychiatry, depression, anxiety, unexplained somatic symptoms
Introduction : The high prevalence of depression in primary care and the low recognition and treatment rates have stimulated the growth of primary care psychiatry.1-2 The current approach has been to borrow from academic psychiatry and attempt to adapt it to primary care practice. This has lead to efforts at educating general practitioners, preparing practice guidelines and conducting courses to improve their clinical skills; however this approach has few takers in actual practice. Recent trends in medicine Two trends have markedly affected the diagnosis and management of psychiatric presentations in primary care. Firstly, as in other medical disciplines, consequent to the decline of family medicine and general practice psychiatric problems presenting to primary care are often viewed from a specialist psychiatric perspective. The reality of primary care is, however, different. Secondly, patients visit general practitioners for various reasons when they are disturbed or distressed, when they are in pain or are worried about the implications of their symptoms. The physician is then compelled to provide a medical label and treatment to justify therapeutic intervention. These result in a mismatch between the needs of primary care psychiatry and what is currently being offered.
Psychiatric diagnosis, classification and treatment In its quest to equate itself with other medical specialties and in the absence of laboratory diagnosis or other pathognomonic evidence, psychiatry uses a collection of symptoms (syndrome), for diagnosis. These diagnostic categories, however, can convey little information about aetiology, treatment and prognosis.2 For example, the term depression is a professional conceptualization that assumes biological dysfunction. However, symptoms of depression are a part of normal mood, a reaction to stress, habitual patterns of coping in people overwhelmed by the demands of life and due to diseases of the brain. They can completely remit, or have a relapsing or a chronic course. The International Classification of Diseases-10 (ICD 10) for Primary Care has a single category of depression into which have been clubbed the numerous categories of depression from the ICD 10 for use in psychiatric settings. As a result, patients with features of biological depression are grouped together with normal people with adjustment reactions due to stress and with those who cannot cope with the demands of life because of poor coping skills. While diagnosis is syndromal, psychiatric treatments, however, remain essentially symptomatic.2 For example, tricyclic and serotonin-specific reuptake inhibitors are used for depression secondary to medical and organic conditions, as well as for depression in schizophrenia, 5

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K. S. Jacob : Management of common psychiatric problems affective disorders, stress related conditions and personality disorders. They are also used in a variety of anxiety disorders including panic, phobia, obsessive compulsive disorder, generalized anxiety and posttraumatic stress. This is also true for psychological treatment concepts and techniques, which are also used across psychiatric categories. The different reality of primary care There are several differences in primary care psychiatry.3 The nature of illness in those who present to general practitioners is often distinct from that seen in tertiary care. The former have milder and less distinct forms of illness, with concomitant psychosocial stress, as compared to those attending a psychiatric hospital with severe, complex and chronic illness and significant motivation to receive specialist treatment. Mixed presentations of anxiety and depression are common in primary care and many patients do not have the complete syndrome attributes of either disorder though they are distressed and have impairment of functioning. Many patients cluster around the threshold used to define psychiatric caseness by research instruments (E.g.11/12 threshold for the Revised Clinical Interview Schedule) making it difficult to for clinicians to accurately identify cases. The cultural background of the patient may determine the mode of presentation with psychological or somatic symptoms. For example, while the most common presentation of psychiatric problems in primary care is with medically unexplained somatic symptoms, a large number of such patients also mention the presence of simultaneous psychological stress or distress on further questioning. Differing conceptual models and perceptions are used in different settings-psychiatrists use medical models while general practitioners focus on the psychosocial context, stress, personality and coping. Management approaches The reality of primary care demands a radically different approach for managing psychiatric problems in primary care. Elaborate and separate protocols and guidelines for managing common mental disorders are often impractical for routine use. Two alternative and complementary approaches, rooted in primary care, have been suggested 3,4 and include: A. Management of common mental disorders without formal diagnosis: This approach advocates that symptom presentation be treated without labels or with neutral diagnostic labels such as functional somatic symptoms and unexplained medical symptoms. These more accurately describe such cases and help to reduce the stigma associated with psychiatric terms. This avoids the distress/disease controversy and allows for a more holistic approach towards patient care. B. The use of a single general protocol for management: Treatment in a psychiatric setting prescribes complex and separate protocols for each traditional syndrome. This kind of an approach may not be necessary nor practical for patients who present to primary care. All common presentations of non-psychotic psychiatric morbidity have common themes in treatment and minor variations in presentations do not warrant major changes in the treatment approach. A general protocol is suggested which does not follow specific theory, but is eclectic and takes into consideration specific concerns of patients who present to primary care. Such a protocol encourages a holistic approach to care, allows for a flexible format that allows incorporation of specific techniques and provides for the treatment of the classic syndrome, if present. A protocol that is simple also ensures use in routine clinical practice. Other approaches and models There are other approaches to treatment of depression that have been advocated. One argues that depression is an explanation promoted by the pharmaceutical industry (which wants to increase the sale and profits from antidepressants), by psychiatrists (who subscribe to the medical model of disease), by general practitioners (who are looking for simple solutions to complex problems) and by societys need for relieving all forms of personal and social distress.5 The author argues for alternative approaches of understanding the thoughts and feelings that we currently describe as depression, drawing on a wide variety of non-medical sources and suggests that we move beyond depression as a medical concept and as a personal problem. Collaborative and stepped care models are alternative approaches which have been shown to be effective in primary care.5 However, these mandate that the physician employ specialist perspectives in their practice and collaborate and refer patients who do not improve. The approach suggested in this paper argues that it is difficult to identify and give psychiatric labels in primary care. It also argues that the current detailed and separate treatment strategies are impractical to employ in routine clinical practice. The specialist approaches advocated by psychiatry dis-empower physicians who then cannot manage such presentations in their clinical practice. In addition, the alternatives suggested by psychiatry (E.g. collaborative and stepped care models) also confirm the inadequacy of physicians in treating the majority of common presentations which present in primary care. The approach advocated, rooted in primary care, argues for managing common presentations (unexplained physical symptoms) without psychiatric labels (avoiding the disease/ distress controversy and the difficult task of making a definite psychiatric diagnosis in Archives of Indian Psychiatry 8(2) October 2007
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K. S. Jacob : Management of common psychiatric problems primary care) and employing simple and easy to use protocols (which increase physician skill and confidence and give them a sense of mastery). Patients who do not respond to these measures will certainly need other interventions including referral to specialist. However, the majority of people who present to primary care will be managed with the approach and protocol suggested. The practicetheory gap The relief of distress among patients who attend primary care is an agreed aim. 3 It is implemented through the different practice guidelines based on the medical model. The many issues discussed above suggest that the current medical diagnostic and therapeutic approaches fall short of the ideal, as they demand diagnosis and subcategorisation and the use of specific treatment protocols. These approaches do not meet the challenge and are therefore inappropriate for the task. There is a need to rework the details and provide for an alternate framework keeping in mind the complex nature of the issues. While the framework suggested does not currently have an evidence base that supports its use in primary care, competent clinicians working in primary care already use similar approaches, which provide for face and content validity. Randomised controlled trials should be used to prove the efficacy and effectiveness of these approaches and narrow the practicetheory gap. Conclusion Clinical presentations of common mental disorders in primary care are often difficult to diagnose and subcategorise. Presentations currently labelled as anxiety, depression or common mental disorders in primary care are illness experiences that do not require disease labels. Diagnostic labels are not necessary for management either, as current psychiatric treatments are essentially symptomatic and are delivered across diagnostic categories. It is suggested that primary care models provide support without medicalising issues. Such an approach is not new and describes existing practice among competent doctors in primary care. The reality of primary care, its problems and opportunities demand unique solutions rather than transplanting practices developed and used in tertiary care and specialist facilities which results in a lack of goodness of fit. The complexity of the issues related to the diagnosis and management of such presentations demand a re-evaluation of the issues. The alternative approaches have to be rooted in primary care so that they are useful and can be successfully employed. There is a need to identify such optimal general protocols and to test their efficacy and effectiveness in clinical practice by using randomized controlled trials. Acknowledgement The author thanks Dr Anju Kuruvilla for help. References 1. Jacob KS. Misunderstanding depression. Natl Med J India 2003; 16: 270-272. 2. Jacob KS. The cultures of depression. Natl Med J India 2006; 19: 218-220. 3. Jacob KS. The diagnosis and management of depression and anxiety in primary care: the need for a different framework. Postgrad. Med. J. 2006; 82: 836 - 839. 4. Jacob KS. A simple protocol to manage patients with unexplained somatic symptoms in medical practice. Natl Med J India. 2004; 17:326-8. 5. Dowrick C. Beyond Depression: A New Approach to Understanding and Management. Oxford: Oxford University Press. 2004. 6. Araya R, Rojas G, Fritsch R, Gaete J, Rojas M, Simon G, Peters TJ. Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial. Lancet. 2003; 361: 9951000
K. S. Jacob, MD, PhD, MRCPsych Department of Psychiatry Christian Medical College Vellore 632002 Email : ksjacob@cmcvellore.ac.in Tel : 0416-2284513

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Editorial
Corporal Punishment In Schools : Are We Still In Stone Age?

Param Shukla
Story on the front paper of a Metro news paperA fourth grader did not bring his home work book and so the teacher slapped him so hard that it damaged his hearing!! Another story on the front paper of a Metro news paper after just few daysA fifth grader was not paying attention in the class and was not listening to the teacher so the teacher made him remove his clothes, touch his toes and stand in heat for so many hours that eventually the boy collapsed!! What is wrong with these cases? They tell us that we are still leaving in the Stone Age where everything was dealt with the corporal ways. They also tell us that this is just tip of the ice burg with many more, probably severe cases, going un reported every single day. The word Corporal comes from Greek and Latin languages roughly meaning physical or pertaining to head. Corporal punishment in common understanding means physical punishment. How can any one even think of relating the word corporal punishment with the words school and children? And yet sadly, it happens every single day, everywhere. In villages, in cities; in private schools, in municipal schools; with rich students, with poor students and with boys and with girls of all ages. They are being slapped, made fun of in front of the entire class by making them stand on the bench and touch their toes, made to stand in blazing heat, bitter cold and hard rain until they are damaged physically, emotionally and psychologically. There is an old Gujarati sayingSoti vage chum-chum, Vidhya aave dham dham!! Roughly it means, you hit the kids, they learn fast!! How far from truth is that!! Physical form of punishment never helps and research is clear that it only makes the problem worse in the long run. How many times we all have seen this? I see this every single day in my practice where the children are being harassed so much for their studies or behaviors in school (and at times by parents) that they Param Shukla, MD (Psych), (USA), Consulting Child and Adolescent Psychiatrist,Ahmedabad Cell : 9879591307 e-mail: Paramshukla@hotmail.com 8
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have one of the 2 common consequences of corporal punishmentExternalizing behaviors: These children become aggressive, hit back, run away from school (Truancy), start telling lies, become oppositional and develop conduct disorder. A dangerous and many times fatal out come is weapons!! Children start carrying knife and even worse- gun with them to school. It used to be happening mainly in America where a harassed, psychologically impaired student will open firing, killing children and teachers. But now it has been reported in India also where students had killed fellow students and teachers with knife. This needs to be stopped, NOW!! Internalizing behaviors: These children go in to a shell. They develop depression, somatization and conversion reaction. They become aloof, lonely and their academic performances go down. The worst of all these is- suicide!! So what should be done? Here are just few suggestions :-
Corporal punishment in schools must be recognized as a form of child abuse and be punished accordingly by Indian Laws. Teacher sensitization training and periodic evaluations. Enforce proper form of behavioral modification training for teachers to properly discipline children. Mandatory liaison between schools and properly trained child psychiatrist/psychologist.
Last but not the least, follow the policy of- praise in public, criticize in private!! As I was writing this editorial, I read the news about three teenagers killing a 6 year old boy they have abducted for money. This is not directly related to this editorial but is another burning issue of todays Indian Youth that needs to be addressed soon by our prominent politicians, lawyers and child mental health experts like us.

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Psychiatric Education
The management of common psychiatric problems in medical practice

K. S. Jacob
Patients with common psychiatric and psychosocial problems often present to primary care. They usually report distressing physical symptoms for which known medical causes are not found. This module discusses a simple approach to managing such patients in primary care. What are the common psychiatric and psychosocial problems seen in primary care? The most common clinical presentation of psychiatric problems in primary is one of unexplained physical symptoms. The reasons for this include: (i) Most psychiatric disorder have somatic manifestations, (ii) People expect doctors to manage physical complaints rather than psychological and social distress and so they often report somatic complaints even if they have significant psychosocial problems, (iii) Physicians with limited training in managing psychosocial and psychiatric disorders selectively respond to physical complaints rather than focus on psychological and social issues. Thus, the most common clinical presentation is that of unexplained physical symptoms. What are the common psychiatric disorders which are seen in primary care? The first stop for people with a variety of non psychotic psychiatric conditions is primary care. The disorders include: anxiety, depression, phobia, panic, obsessive compulsive disorder, and problems secondary to acute and chronic stress. How common are psychiatric syndromes in primary care? Many studies have been done in primary care. Most report between one third to one fourth of patients attending a general medical clinic have diagnosable psychiatric disorders. What happens to patients who do not get help from physicians? The absence of physical cause for such problems often results in the physician downplaying their importance or ignoring the distress. Many patients are often dissatisfied with the medical care they receive and consequently shop for different treatments. If psychiatric presentations are so common in primary care why is it difficult to recognise and manage these in Archives of Indian Psychiatry 8(2) October 2007
clinical practice? There are many reasons for discomfort among physicians in managing psychiatric disorders in primary care. These include: (i) Most medical teaching programs for physicians focus on the classical cases with definite physical signs and underlying medical causes. Patients with medically unexplained symptoms are rarely discussed during clinical teaching. (ii) Most psychiatric training programs are based in specialist settings, employ complex psychiatric perspectives and management strategies, and promote the acquisition of knowledge rather than skill and confidence in managing these conditions. Consequently, many physicians are uncomfortable with managing such patients in their practice. What are the traditional explanations offered for the lack of skill in diagnosis and management of psychiatric disorders by general physicians? These explanations and possible alternatives are listed in Table I. Table 1: Explanations for the lack of skill among physicians in managing common psychiatric disorders in general hospital settings A. Traditional explanations 1. Lack of knowledge. 2. Lack of motivation. 3. Lack of time. 4. Lack of training. 5. Poor quality of students and clinicians. 6. Psychiatry is not interesting. 7. Psychiatry is too complex/ vague. 8. Psychiatrists are poor teachers Alternative explanations 1. Psychiatrists do not understand the reality of medical settings 2. Psychiatry has not understood the needs of clinicians working in general hospital settings. 3. Training programs in psychiatry for clinicians satisfies the needs of psychiatrists. 4. Training programs in psychiatry are not appropriate for physicians. 9
B.
K. S. Jacob : The management of common psychiatric problems in medical practice Characteristic Severity of illness Complexity of problems Chronicity of disease Distinct/Mixed presentations Motivation to seek psychiatric treatment Psychosocial/genetic predictors of outcome Availability and expertise of doctors Cost: time and money Psychiatric facility Usually severe Usually complex Usually chronic Distinct presentations Present Genetic and disease predictors important Specialist expertise available Usually prolonged consultations General Medical setting Often mild Often simple Often brief Mixed presentations Common May be absent Psychosocial predictors usually important Physician perspective and expertise available Often brief and inexpensive
Traditional explanations have always blamed the general practitioners not managing common psychiatric problems while absolving specialists of all responsibility. The alternative explanations suggest that psychiatrists who work in tertiary hospitals do not understand the reality of primary care and that psychiatric protocols are complex and not relevant and practical to the setting. Will I be able to diagnose and manage patients with psychiatric problems attending primary care if I am specifically taught about them? Many studies have documented low recognition and treatment rates for common psychiatric problems in primary care. The situation has persisted despite improved psychiatric training for GPs. Brief screening instruments (E.g. General Health Questionnaire-12) have also been suggested as simple measures for the diagnosis of common psychiatric problems in primary care. These instruments have been shown to have good sensitivity and reasonable specificity. However, their predictive values, at the prevalence level of common psychiatric disorders seen in primary care, leave a lot to be desired. They often result in high false positive rates. In addition, while psychiatrists claim that these instruments identify people with disease, the general practitioners argue that they simply recognise people in distress. The use of medical and psychiatric labels in people with personal and social distress is also stigmatising. The strategy of managing people with unexplained somatic symptoms without making a formal psychiatric diagnosis overcomes these problems. The use of this strategy will allow you to manage such patients in your practice. You will also derive a lot of satisfaction from doing so and will be able to help many more people in distress. How will this training be different from the training I already received and which has not equipped me to treat the psychiatric problems of my patients? 10
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This module is based on patients who attend primary care and their problems. It also employs very simple physician based perspectives, is jargon free and suggests management steps which can be used in day to day situations in busy medical and surgical practice. What are the differences between patients attending a psychiatric hospital and those patients who present to primary care? The many differences are listed in Table II. Table 2 : The differences between depression presenting to psychiatric and to general medical settings So how do patients who attend primary care manifest their psychiatric and psychosocial problems? The majority of patients in primary care present with unexplained physical symptoms. Very few patients report with psychological distress as a presenting complaint. Will they also have the symptoms of anxiety, depression,? Yes, they may have such symptoms. Will I be able to diagnose anxiety, depression and other psychiatric syndromes? While patients may report these symptoms it is often difficult to differentiate these syndromes in patients who present to primary care. The reasons are: (i) The symptoms are often mild, (ii) Some symptoms like weakness, tiredness, difficulty in concentration, sleep disturbance are seen in both anxiety and depression syndromes. (iii) The symptoms of anxiety and of depression are commonly seen in the same patient. This means that the classical syndromes are unlikely to be differentiated in patients who present to primary care. This also applies to the other syndromes like phobia, panic, obsessive compulsive disorder etc. Archives of Indian Psychiatry 8(2) October 2007
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K. S. Jacob : The management of common psychiatric problems in medical practice Will I be able to manage such patients without reaching a specific diagnosis? Yes you will be able to treat such patients. All these syndromes usually require antidepressant medication and psychological support. The steps are mentioned in this module. Will a single protocol help different types of patients? Yes. The protocol contains all the essential steps in management of these conditions. If a single protocol is useful why are there so many different management guidelines for anxiety, depression, and the other psychiatric syndromes? Many of these guidelines are derived from specialist settings and may be useful for patients with severe and chronic disease. They may not be necessary for patients who present to primary care. In addition the different protocols are complex and often not easily employed in the primary care setting. What is the basis of the suggested protocol? The ten step approach described is based on the reattribution model1. This method has been taught to primary care physicians, medical students and residents in psychiatry for the past 6 years and has been found to be useful in clinical practice. The steps, the sequence and their rationale are briefly described. What are the ten steps? 1. Acknowledge distress 2. Elicit patient perspective 3. Focused physical examination and laboratory investigations 4. Provide specific reassurance for symptoms 5. Discuss alternative explanations for symptoms 6. Prescribe medication 7. Suggest general coping techniques 8. Discuss specific stress reduction 9. Transfer responsibility 10. Appointment for review Step I : Acknowledge distress Acknowledging the distress caused by the physical symptoms reassures the patient that their symptoms have been carefully considered. The failure to do so is often interpreted by patients as an indication that the physician has not understood the problem or that he/she does not believe that the symptoms to be genuine. Acknowledging distress reflects an empathetic attitude, contributes to establishing an effective rapport and the formation of a therapeutic alliance which are essential in facilitating improvement. Step II : Elicit patients perspective on symptoms Providing appropriate reassurance is an important part of the medical consultation. It is most effective if based on the patients actual concerns. Asking patients what they think or fear is wrong with them is useful in Archives of Indian Psychiatry 8(2) October 2007
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addressing specific concerns (E.g. It could be cancer). Many of beliefs held by patients with unexplained physical symptoms contradict the biomedical model of their illness2. Patients beliefs need to be discussed prior to presenting alternative biomedical explanations. Outright rejection of patients beliefs about their illness early in the consultation or a failure to elicit them often proves disastrous. Eliciting such explanations will also allow for focussed examination, investigations and specific reassurance. Step III : Focussed history, physical examination and laboratory investigations Physical disease, substance dependence and psychosis (E.g. presence of strange beliefs, hallucinations and grossly abnormal behaviour) have to be excluded. A focused history, physical examination and laboratory investigation to exclude physical disease is cardinal. This will go a long way in reassuring the patient that medical causes have not been overlooked. The use of alcohol and tobacco should also be enquired into. A cursory examination, on the other hand, is interpreted by the patient that a serious attempt was not made to rule out medical disease and leaves them dissatisfied with the consultation. Step IV : Reassure patients about symptoms Reassurance is crucial in allaying the patients concern and changing their help seeking behaviour3. A common expectation among patients is a better understanding of their symptoms. Being told that there is no serious medical problem underlying their symptoms is effective in reducing the health concern for many patients. However, for a significant number such reassurance alone is not helpful, resulting in further needless consultations. Evidence suggests that for reassurance to be effective the patients concerns need to be elicited and appropriate explanations provided. Worry about their health is bound to recur if the symptoms persist especially if the patients lack a satisfactory explanation that enables them to interpret their symptoms as benign. Consequently, it becomes necessary manage the patients beliefs, misconceptions and concerns about health. Explanations which completely deny all disease often makes patients wonder if the doctor disbelieves their symptoms. The emphasis should be on reassuring the patient about the absence of any serious physical disease while acknowledging the reality and distress of the symptoms. The possibility of a catastrophic event or incapacitation being highly unlikely should be reiterated. Alternative explanations for these symptoms (i.e. the individuals tendency to interpret innocuous bodily sensations as bodily dysfunctions or symptoms related to stress) are useful.
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K. S. Jacob : The management of common psychiatric problems in medical practice Step V : Mention relationship between stress and symptoms Discussing the link between physical symptoms and stress is crucial. Simple explanations of possible links between anxiety and stress causing physical symptoms or how depression lowers the pain threshold are useful. Asking if anyone else in the family or among friends has suffered from similar symptoms also helps patients identify such mechanisms. Interpersonal problems, financial difficulties, alcohol dependence in spouse and physical abuse are commonly reported by these patients, usually on enquiry. Other stressors which also cause anxiety include sexual misconceptions (E.g. Dhat syndrome) and dysfunction in men and a fear of unwanted pregnancy in women who are not practicing contraception. Step VI : Prescribe medication Most patients expect medication. Not prescribing any medication often results in patient dissatisfaction. Antidepressant medication is useful and can be prescribed if depression, anxiety, panic, phobia or obsessive compulsive symptoms are present. They can also be prescribed in conditions where pain is incapacitating (e.g. headache, irritable bowel syndrome, atypical chest pain). Serotonin selective reuptake inhibitors are generally preferred to tricyclic antidepressants as they have fewer side effects. However, tricyclic antidepressants are favored in patients with insomnia (Appendix). Benzodiazepines are best avoided as they produce dependence if prescribed for more than one month. Patients without such symptoms can be given vitamins and the placebo response often helps them cope with their circumstances. Step VII : Suggest general stress reduction strategies Recommending general psychological measures like yoga or meditation, regular physical exercise, involvement in religious activities, hobbies and leisure improve coping and are useful for those under stress. Incorporating such activities into the patients daily routine is cardinal for success. Discussing the need to reduce the use tobacco and alcohol changes in lifestyles will also prove useful. Step VIII : Explore possible specific measures to reduce stress Specific education and treatment for sexual misconceptions, dysfunction and the lack of contraception is helpful for these conditions. However, while some forms of social adversity can be easily altered, many require a change in philosophy, attitude and life style. Patients with specific problems will need help with problem solving. Often life situations may be difficult to resolve and may require acceptance and change in coping strategies. Asking patients to look for specific solutions to their difficulties and giving them time to examine the issues is obligatory. Step IX : Transfer responsibility for improvement 12
Innovative Infotech / P-IV / D:\Dr. / 12 G.K.
Most patients expect cures from doctors and come back with the same or new complaints for the physician to resolve. The responsibility for improvement should be gently but firmly transferred to the patient. The offer of psychological support will help patients cope with stress. Step X : Give a specific appointment for review Regular review of progress is necessary for most patients with scheduled, brief appointments every two to four weeks (i.e., avoiding as-needed appointments). A brief, focused physical examination must be performed at each visit that helps rule out any new or worrisome condition and provides the patient with the important benefits of laying on of hands. The physician should gradually shift the focus away from the patients physical symptoms to the psychosocial context that may be most affecting them. Restoration of function must be the treatment goal rather than complete symptom elimination. Most patients will accept this when they realize that their life circumstances are the cause of their symptoms. These visits can be used to provide psychological support and to discuss alternative coping strategies. Will I be able to do this in my busy clinical practice? Yes. Physicians often worry that managing psychosocial problems takes time. With practice the efficiency of the technique used improves and such counselling can be used in real-life situations. Even long interviews do not usually last more than 10-15 minutes. Will I be able to solve the patients psychosocial problem? Physicians also hesitate to get involved because of the fear that they will not be able to solve the patients troubles. The realisation that it is not the physicians responsibility to solve the patients social difficulties but to empower patients to resolve it themselves comes with experience. The specific solution to social adversity has to be the patients own. Such realisation is liberating and allows the physician to help people with stress without feeling the compulsion to solve their problems. How can I begum skill at such treatment? While the knowledge of the treatment process can be easily assimilated, the mastery of the skill required to manage such patients requires rehearsal. With regular practice, physicians acquire competence and confidence in their ability to handle patients with such presentations. Mastery of the technique increases the satisfaction a physician derives from the process. Such success reinforces their behaviour and they consequently recognise and treat more patients with such presentations. When should I refer a patient for specialist help? Referral to specialists should be avoided as these patients are best managed in primary care settings. Psychiatric evaluation and specialist counselling may be necessary for incapacitating mental disorders, intractable interpersonal difficulties and for persistent sexual dysfunction and substance dependence. Archives of Indian Psychiatry 8(2) October 2007
K. S. Jacob : The management of common psychiatric problems in medical practice Medication Starting dose 25 mg Adult dose 50-150 mg Common side-effects Indications* Duration of treatment 3- 6 months followed by a tapering schedule. Can be continued for many years if relapse of symptoms on withdrawal
Dothiepin, Imipramine, Amitriptyline Mirtazapine
7.5mg
15 mg
Sedation, giddiness, dry mouth, constipation Sedation
Fluoxetine Sertraline
20 mg 25mg
20 mg 50-100 mg
Nausea, restlessness
Conditions associated with disturbed sleep Conditions associated with disturbed sleep; Cardiac disease Conditions without sleep disturbance
Establishing a working relationship with a psychiatrist who understands primary care is essential. Referral for clarification and for advice on difficult patients or complex presentation is useful. In addition, follow up of cases who return to primary care after specialist intervention will require cooperation from the specialist. Specialist on their part will need to empower physicians to manage patients in primary care rather than take over management of all patients referred for specialist intervention. Conclusion Acknowledging the distress caused by symptoms, reassuring patients about the absence of serious physical illness, exploring and managing stress, recognising and treating psychiatric syndromes are necessary components of treatment packages for subjects with unexplained physical symptoms. Providing alternative explanations for the symptoms within the supportive context of a doctor patient relationship and encouraging patients to pursue alternative coping strategies will help change knowledge and attitudes related to the illness and consequent practice. Appendix 1 : Anxiety : The apprehensive anticipation of future danger or misfortune accompanied by feelings of dysphoria or somatic symptoms of tension. The focus of the anticipated danger may be internal or external. Depression : The persistent sadness, low mood and loss of interest or pleasure in nearly all activities. It is often associated with sleep disturbance, loss of appetite and weight, decreased libido and suicidal ideation. Obsessive compulsive disorder : The presence of recurrent obsessions (persistent ideas, thoughts, impulses, or images which are experienced as intrusive and inappropriate and cause marked anxiety or distress), or K. S. Jacob, MD, PhD, MRCPsych Professor of Psychiatry, Christian Medical College,Vellore 632002 India .Email: ksjacob@cmcvellore.ac.in Archives of Indian Psychiatry 8(2) October 2007
compulsions (repetitive behaviors or mental acts who aim is to reduce anxiety). These are often time consuming, distressing and cause significant impairment in functioning. The patients can appreciate the irrational nature of the obsessions and compulsions. Panic : The sudden onset of intense apprehension, fearfulness and terror often associated with a feeling of impending doom. These episodes last for short duration (less than 30 minutes) and may be associated with anticipatory anxiety and phobic avoidance Phobia: A persistent, irrational fear of a specific object or situation that results in a compelling desire to avoid it. This often leads either to avoidance of the stimulus or situation or to enduring it with dread. Appendix 2 : Common medication, their side-effects, indications, dosage and duration of treatment Indications include unexplained physical symptoms, depression, anxiety, panic, phobia, obsessive compulsive disorder Acknowledgement: This module was developed and first employed in the Community Health and Development Hospital, Christian Medical College, Vellore 632002 India. It is now routinely used to teach medical students, nurses, physicians and psychiatrists in the medical school. Further reading 1. Jacob KS.The diagnosis and management of depression and anxiety in primary care: the need for a different framework. Postgrad. Med. J. 2006; 82: 836 - 839. 2. Jacob KS.A simple protocol to manage patients with unexplained somatic symptoms in medical practice. Natl Med J India. 2004; 17:326-8. 3. Jacob KS. The cultures of depression. Natl Med J India 2006; 19: 218-220.
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D:\Dr. / 13 G.K. Vankar (Hemang)\Journal(4-5-2009).p65
Dr. Jitendra Nanawala

Presidemt, Indian Psychiatric Society, Western Zonal Branch 2008
Dr. Jitendra Nanawala had his M.B.B.S. from Medical College ,Baroda, M.S. University 1979, D.P.M. & M.D. from B.J.Medical College,Ahmedabad, from Gujarat Uniiversity in 1982 - 83, passed at first attempt. Apart from medical studies, he also did Diploma in German language from M.S. University and Post-graduate diploma in Human Resource Management from IGNOU. Dr. Nanawala worked at Hospital for Mental Health, Ahemedabad, as medical officer, resident medical officer and as in charge superintendent. During this tenure he also established and run the Community Mental Health unit at Godhara district Civil Hospital for two years. He also initiated psychiatric services at Civil Hospital, Navsari. As Honorary Psychiatrist. He is member of Navsari District Mental Health Society. He is also Hon. Psychiatrist to Ashktashram, Burhani, Lokhat General Hospital, and Maskati Hospital, Surat.
He was selected by U.K. government for international fellowship scheme and traveled to U.K. twice. He also worked as research officer for WHO Epidemiological Study of prevalence of psychiatric illnesses in population of Navsari District. As a part of philanthropic activities, he has initiated and established Community Mental Health Program for the tribal district of Dang for two years. He also worked for implementation of District Mental Health Programme for Navsari district and trained the staff of public health for Mental Health. He also actively contributed in activities of Mental Health Mission of Government of Gujarat. He was Hon. Secretary of IPS Western zonal branch for last four years. He was also Treasurer, Council Member of IPS from Western Zonal Branch. He is consultant psychiatrist to Taluka Mental Health Programme for Gandevi Taluka, in Navsari district.
Correspondence : Jitendra Nanawala, MD Consultant Psychiatrist 4 / Raj Cambers, Unapani Road Surat 395 003 e-mail:shojit@dataone.in Cell: 09825136289
14

Presidential address
Suicide: Western India Context

Jitendra Nanawala
Respected chairpersons and members of the Indian Psychiatric Society (IPS), I am extremely happy and privileged to be here at the 37 th Annual Conference, before an enlightened gathering to preside over the prestigious IPS-WZB. It is a rare honour and it shall be my endeavor to prove myself worthy of being chosen for this prestigious and highly coveted honour among the psychiatrists. I shall endeavor my best with the cooperation and support of all my fellow psychiatrists. There were many topics, which flooded my mind when I started thinking about the Presidential address, but I choose the topic of suicide as we decided to focus in this conference on suicide, as it is very much prevalent in this part of Maharashtra and burning issue of present time. I am not researcher neither academician but a clinician, the next question that erupted in my mind is what is really happening in our country and our zone as far as suicide is concern. Whether we are facing unprecedented rise in suicide rate or is it media hype? I tried to search for the answers and I came across many interesting articles and I decided to share them with you. My other main obsession was what could we do as body for this burning problem? I will focuses in my talk on suicide in context of our country and especially our zone and what we can do. Suicide is a huge but largely preventable public health problem, causing almost half of all violent deaths and resulting in almost one million fatalities every year, as well as economic costs in the billions of dollars. Suicide is a tragic global public health problem. Worldwide, more people die from suicide than from all homicides and wars combined. There is an urgent need for coordinated and intensified global action to prevent this needless toll. Rates tend to increase with age, but there has recently been an alarming increase in suicidal behaviours amongst young people aged 15 to 25 years, worldwide. Accidental death and suicide clock-2005 200 suicides by male per day lost their lives by committing suicide during the year 2005. This showed a marginal increase of 0.2 per cent over the pervious years figure (1,13,697). The population has increased by 20.4 per cent during the decade and the rate of suicides has increased by 6.2 per cent. The rate of suicides has shown a declining trend since 1999. ncidence and Percentage Share of Suicides in States of Maharshta, Goa & Gujarat, Dadara Nagar Haveli, Diu & Daman. Maharashtra reported the second highest number of suicide, it is that 14,426, accounting for 12.7 per cent. Gujarat accounted for 4.2 percent. Surprisingly the U.T. of Diu & Daman and Dadra Nagarhaveli reported significant increase in suicide during 2005 as compared to 2004, 146.2 for Daman & Diu and 76.9 for Dadara-Nagarhaveli.(1) The rate of suicide for Maharashtra is 14.0, Goa 18.7, Gujarat 8.8, Dadara Nagar Haveli 28.3, Daman & Diu 18.3. The national average is 10.3. Their rank is 14th,9th, 19th,3rd and 11th, respectively. City wise the rank are as, Rajkot 5th,Nagpur is 7th, Nasik 9th, Pune 15th, Surat 17th, Vadodara 18th, Ahmedabad 20th & Mumbai 26th. Causes of Suicides : Failure in examination Dowry disputes Poverty Bankruptcy or sudden change in economic position Love affairs Causes not known Illness Family problems Other causes 2.0%
2.7% 3.1% 15.3% 22.0% 22.3% 28.3%
10.7 10.6 10.5 10.4 10.3 10.2 10.1
10.6 10.5 10.4 10.3 10.5
112 suicides by female per day out of which 66 were housewives
51 deaths per day due to sudden death(like heart attack etc.) Suicides in India Incidence and Rate of Suicides during the Decade (19952005) More than one lakh persons (1,13,914) in the country
2001
2002
2003 Line 1
2004
2005

15
Jitendra Nanawala : Suicide : Western India Context
No. Suicide State/U.T./City Goa Maharashtra Gujarat Daman&Diu Dadara N. H. Rajkot Nagpur Nasik Pune Surat Vadodara Ahmedabad Mumbai 282 14,426 4765 32 69 250 416 209 506 365 179 468 1192
% of total Suicide. .02 12.7 4.2 0.0 .1 2 3.4 1.7 4.1 3. 1.5 3.8 9.7
Rate
Rank
18.7 14 8.8 18.3 28.3 25 19.6 18.1 13.6 13.0 12.0 10.2 7.3
9 14 19 11 3 5 7 9 15 17 18 20 26
Self employed category accounted for 39.4% of victims. It comprised of 15.0 per cent engaged in Farming / Agriculture activities, 5.5 per cent engaged in Business and 2.4 per cent Professionals. It was observed that 70.8 per cent of the suicide victims were married while 21.0 per cent were unmarried. Divorcees and Separatees have accounted for about 3.7 per cent of the total suicide victims. The proportion of Widow & Widower victims was around 4.6 per cent. Daman & Diu, 43.8 percent, unmarried against 21.0 per cent at National level. 87.0 per cent of victims in D & N Haveli were married against the national average of 70.8 per cent. 16
Educational Status of Suicide Victims Uneducated 23.0% Primary 25.8% Secondary 24.0% Higher Secondary 7.4% Diploma 0.9% Graduate 1.8% Postgraduate and Above 0.4% The maximum numbers of suicides victims were educated up to Primary level (25.8%). Illiterate and middle educated suicide victims accounted for 23.0 per cent suicide victims and 24.0 per cent respectively. Only 2.1 Archives of Indian Psychiatry 8(2) October 2007
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Jitendra Nanawala : Suicide : Western India Context Percentage share of Suicides Committed by Consumption of Poison and Hanging 2005 Poison India Gujarat Maharashtra Daman and Div Goa D & N Haveli Total 1891 5567 12 154 42 % 36.6 38.6 39.7 37.5 54.6% 60.9 Hanging India Goa Maharashtra Total 154 4979 % 32.1% 54.6% 34.5%
per cent suicide victims were graduates and postgraduates. 43.5% suicide victims in D&N Haveli, were illiterate, 39.5 per cent in Gujarat had education up to primary level. The majority of suicide victims are illiterate or having only primary level education. Means Adopted for Committing Suicides The means adopted for committing suicide varied from the easily available means such as consumption of poison, jumping into the well, etc. to more painful means such as self inflicted injuries, hanging, shooting, etc. Suicide by Consuming Poison (36.6%), Hanging (32.1%), Self Immolation (7.9%) and Drowning (6.8%) were the prominent means of committing suicides as in past. Poisoning and hanging seems to be most common methods of committing suicide, it is common in the young age group of 15 to 45 yrs. Examination fear is major cause among the young children up to the age of 14 years. Suicidal behaviour has a large number of complex underlying causes, including poverty, unemployment, loss of loved ones, arguments, breakdown in relationships and legal or work-related problems. A family history of suicide, as well as alcohol and drug abuse, and childhood abuse, social isolation and some mental disorders including depression and schizophrenia, also play a central role in a large number of suicides. Physical illness and disabling pain can also increase suicide risks. Currently attention is focused on encouraging a reduction in access to pesticides and encouraging enhanced surveillance, training and community action on their use, for example, safer storage, and proper dilutions. Protective factors against suicide include high selfesteem and social connectedness, especially with family and friends, having social support, being in a stable relationship, and religious or spiritual commitment. Early identification and appropriate treatment of mental disorders is an important preventive strategy. There is also evidence that educating primary health care personnel in the identification and treatment of people with mood disorders may result in a reduction of suicides amongst those at-risk, as it has been documented in countries such as Finland and in the United Kingdom. Archives of Indian Psychiatry 8(2) October 2007
Interventions based on the principle of connectedness and easy access to help such as Samaritan-type help lines, and telephone check-up programmes on the elderly, have provided encouraging results. In addition, psychosocial interventions, suicide prevention centers and school-based preventions are all promising strategies. The depression masquerades under many `proxies simulating diverse physical illness. It has been said of depression: it takes 10 years and three doctors to arrive finally at the diagnosis of depression (Whybrow,1997). Evidence also suggests that media reporting can encourage imitation suicides and we would urge that the media show sensitivity in its reporting on these tragic and frequently avoidable deaths, The media can also play a major role in reducing stigma and discrimination associated with suicidal behaviours and mental disorders. The relative impact of different strategies on national suicide rates is important for planning but difficult to estimate. The different interventions impact, on national suicide rates shows that the most promising interventions are physician education, means restriction, and gatekeeper education. (JAMA, 2005),7 Suicide is a complex phenomenon that has attracted the attention of philosophers, theologians, physicians, sociologists and artists over the centuries; according to the French philosopher Albert Camus, in The Myth of Sisyphus, it is the only serious philosophical problem. As a serious public health problem it demands our attention, but its prevention and control, unfortunately, are no easy task. State-of-the-art research indicates that the prevention of suicide, while feasible, involves a whole series of activities, ranging from the provision of the best possible conditions for bringing up our children and youth, through the effective treatment of mental disorders, to the environmental control of risk factors. Appropriate dissemination of information and awareness rising are essential elements in the success of suicide prevention programmes. Suicide and mental disorders Suicide is now understood as a multidimensional disorder, which results from a complex interaction of biological, genetic, psychological, sociological and 17
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Jitendra Nanawala : Suicide : Western India Context environmental factors. Research has shown that between 40% and 60% of people who commit suicide had seen a physician in the month prior to suicide; of these, many more had seen a general physician rather than a psychiatrist. As a body we can take up training of family physician in management of suicidal patients to prevent suicide. We can start with training of colleagues to train the family physician. We have ready to use excellent module prepared by WHO for the same. We can collaborate with our state branch and start training for psychiatrists who will work as resources person for the respective state. At next stage we collaborate with IMA of respective state and can carry out training at local level. We can also collaborate with public health department of state and can help them to train doctors working in PHC, CHC and district hospitals. With this programme we can make significant difference in reducing suicide rate. Good mental health care and mental health promotion can reduce the risk of suicide among people with a mental illness. Suicides should not be seen as a tragic and unavoidable aspect of mental illnesses. Public awareness campaigns to increase awareness of suicide as a problem that is preventable; to develop broad-based support for prevention efforts; to reduce stigma. Means restriction initiatives to reduce access to lethal means and methods of self-harm. The risk of mental health problems and suicide is also heightened for groups on the edges of society (migrants and refugees) as well as inmates and former inmates. Any programs that support societys weakest members and strengthen community institutions (such as home and school) indirectly but powerfully decrease the risks of mental health and suicide. Providing support after suicide attempts A small number of interventions, which focus on enhancing treatment and support for these people, have been shown to reduce the risk of repeated suicidal behaviour. A Norwegian initiative which focused on providing follow-up care to people after discharge from hospital after making suicide attempts via an integrated chain-of-care network was shown to be effective in reducing further suicide attempts and in maintaining adherence to treatment regimes. A programme that employed case managers to follow up primary care patients was effective in encouraging patients to keep appointments and to adhere to medication and treatment regimes. Relatively simple interventions, which consisted of sending letters to people who had been discharged from inpatient psychiatric units or medical units following 18
admission for self-poisoning, have been shown to reduce suicide attempts and suicides. Older men were more likely to commit suicide than younger men. Most women who committed suicide were aged 15-24 or older than 65. We found more suicides among women (102/278) than among men (58/331) in the 15-24 years age group. (Joseph) The independently verified method used verbal autopsies and found the rate in 1994-9 was 95.2/100 000 populationnine times the national average. The high rates are not likely to be peculiar to Kaniyambadi; they reflect more accurate data collection. Sentinel centres that accurately monitor suicide are needed in the developing world. From the report of NCRB, it seems that the suicide rate has not increased dramatically during the decade; it is proportional to the rise in population. As far as our zone is concerned Maharasthra leads with large numbers of total suicide, highest incidence is in UT. We must put in very concentrated efforts for these two areas. In world literature marriage offers some protection from suicide but in our country and zone this seems to be contrary and more married people are committing suicide. This may be because of arranged marriage system and no easy way out of estranged marital relationship. We must educate the society for the same. Education level of the person who commits suicide is very low, so we must keep this in mind while preparing any strategy for prevention. What can be the better ways to reach them? The self employed group is at greater risk, this include farmers too as they fall under the same category. More support to such group is needed. The main means employed to commit suicide is poisoning, so better method of dispensing and storage along with more education of user group is the right choice for prevention of suicide. Hanging is also popular means employed in UT, Maharashtra and Goa, how to prevent this needs more research and attention from our zone. Mental illnesses are not listed as one of the major reasons for committing suicide. Considering the close association between this two, we must advocate for improvement in method of reporting to NBCR, so this anomaly can be taken care of. The most successful intervention is the educating the family physician for the prevention of suicide. I think, we as a mental health professional play bigger role in this. This is practically feasible. We must take up this exercise at our level and contribute towards well being of the society at large. References: 1. Government of India (1994) Accidental deaths and suicides in India, National Crime Records Bureau, Archives of Indian Psychiatry 8(2) October 2007
Jitendra Nanawala : Suicide : Western India Context New Delhi: Ministry of Home Affairs. Prasad, J., Abraham,V. J.,Minz, S., et al (2005) Rates and factors associated with suicide in Kaniyambadi Block,Tamil Nadu, South India, 2000^02. International Journal of Social Psychiatry. Joseph, A., Abraham, S.,Muliyil, J. P., et al (2003),Evaluation of suicide rates in rural India using verbal autopsies,1994-99. BMJ, (2003),326,1121-1122. Aaron R, Joseph A.,Abraham S, et al. Suicides in young people in rural southern India. Lancet 2004, 363:1117-18 Abraham VJ, Abraham S, Jacob KS, Suicide in the elderly in Kaniyambadi block, Tamilnadu, South India. Int J Geriatr Psychiatry 2005:20:953-5 Whybrow,P.C. (1997) A Mood Apart a Thinkers Guide to Emotion and its Disorders. Published by Basic Books, a division of Harper Collins Publishers Inc.,USA. Mann JJ; Apter A, Bertolote J et. al. Suicide Prevention Strategies-A Systematic Review, JAMA. 2005;294:2064-2074. Angst J, Angst F, Stossen HM. Suicide risk in patients with major depressive disorders. Journal of clinical psychiatry, 1999, 60, Suppl. 2: 57-62. Rihmer,Z., Barsi,J. & Rutz,W.(1990) Suicide rate, prevention of diagnosed depression and prevalence of working physicians in Hungary. Acta Psychiatrica Scandinavica, 88, 391-394. Rutz W, von Knorring L, Walinder J. Long-term effects of an education programme for general practitioners given by the Swedish Committee for Prevention and Treatment of Depression. Acta psychiatrica scandinavica, 1992, 85: 83-88.
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Jitendra N.Nanawala MD Consultant Psychiatrist 4 / Raj Cambers, Unapani Road Surat 395 003 e-mail:shojit@dataone.in Cell: 09825136289

19
Dr. L. P. Shah Oration
Child And Law

P. C. Shastri
When men are pure, laws are useless, when men are corrupt, laws are broken - Benjamin Disraeli 19th century. The subject of law relating to child and adolescent has always endeared me. The various laws pertaining to child have arrived in statute book in recent years. General or even particular awareness about this law in the public, among the professionals or all those concerned with child and adolescent mental health sector has been only marginal. Present paper only makes an attempt at building awareness and stimulate action plan to fulfill the dream of all rights being converted to law and implemented at center, state, society, family and judiciary at the earliest. Waiting for sixty years for child mental health policy, mental health policy for disable in present 11th five years plan is too long a wait for billion plus Indians. Having been associated with people and organizations working in the field of child and adolescent mental health and various groups of children with special problems and needs, I feel the need to evaluate and have overview of large number of relevant legislation, statutory rules and regulation that have concern with children. However, I do not plan to address every reference from High court, Supreme Court of India, United Nations resolutions, convention and instruments which make the basis of legal aspect of child and adolescent mental health. National Human Rights Commission will guard right to education and health. Focus will be on life, survival, health and basic education. Elementary education and primary health services in rural areas will get top priority. S. Rajendra Babu Former Chief Justice of India, Chairperson of NHRC September 2007 Dr R. Shrinivasmurthy (1993) also has noted the clinical preoccupation of the available mental health professionals of the country and the delay of these professionals to spearhead work towards rectifying this major lacuna in liaison with the sectors like welfare, education, labour, health along with law over the years. India presents a unique case in terms of the sheer size of its population and 46 percent of them are children; characterized by heterogeneity in respect of physical, Delivered At 38 th Annual At Nagpur 14th October 2007 20
economical, social and cultural conditions. Its population of 1.12 billion constitutes 16 percent of the world population, with 74 percent of them living in rural areas. India is a secular state with various languages, cultures and religions. It has 31 states, 1618 languages, 544 dialects and 1942 mother tongues, with 148 mediums of instruction at school level. India publishes more than 27,000 daily newspapers and periodicals covering the range of languages and cultural diversity unparallel to any other country in the world. 6400 caste and six religions make universal acceptance of any program difficult. This kind of complex and multifaceted country makes formulation of National policies, programming and planning quite a challenging task. Each and every one of the 600 districts of India is unique in many ways. Each district will need its planning at local level. For such a diversified country it is difficult to envisage a national program that fits all and even of all are considered in reality it may fit none. The constitution of India envisages the establishment of new social order based on equality, freedom, justice and the dignity of the individual. It aims at the elimination of poverty, ignorance and ill health and directs the state with regard to raising the level of nutrition and of the people; securing the health and specially ensuring that children are given opportunity to develop in a healthy manner. India has been a signatory to all the resolutions including the latest passed on the 1st January 1996 which states that every child will have equal opportunities, protection of rights and full participation. (The Person with Disability Act 1995). After six decades of independence we have managed to resolve to help the Indian child. Child has never been given even minimum attention and essential requirements in last six decades. It is not surprising that under the minimum need programs, in last 10 years, outlays and expenditure under health sector though very small, are never spent. India is home to almost 19 percent of the worlds children. More than one third of the countrys population, around 480 million, is below 18 years. 560 millions are below the age of 25 years (54% of the population).
Conference
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P. C. Shastri : Child And Law According to one assumption 40 percent of these children are in need of care and protection, which indicates the extent of the problem. In a country like India with its multicultural, multi-ethnic and multi-religious population, the problems of socially marginalized and economically backward groups are immense. Within such groups the most vulnerable section is always the children. For the Ministry of Women and Child Development the challenge is to reach out to the most vulnerable and socially excluded child of this country and create an environment wherein, not only is every child protected, but also has access to opportunities and education for all round growth and development. Growth alone does not deliver people out of poverty. Government must focus on the single biggest cause of vulnerability in health spending. A concerted focus on public health can change the lives of millions. National commission for enterprise in unorganized sector (NCEUS) reports 77% of the population living below the poverty line (Rupees 20 per capita). Independent India has taken large strides in addressing issues like child education, health and development. But, it has failed to implement program which is progressive, promotional, performance based, preventive and protective to the child. However, child protection has remained largely unaddressed. There is now a realization that if issues of child abuse and neglect like female foeticide and infanticide, girl child discrimination, child marriage, trafficking of children and so on are not addressed, it will affect the overall progress of the country. Traditionally in India, the responsibility of care and protection of children has been with families and communities. A strong knit patriarchal family that is meant to look after its children well has seldom had the realization that children are individuals with their own rights. While the Constitution of India guarantees many fundamental rights to the children, the approach to ensure the fulfilment of these rights was always more need based rather than rights based. The transition to the rights based approach in the Government and civil society is still evolving. It has very clearly emerged that across different kinds of abuse, it is young children, in the 5-12 year group, who are most at risk of abuse and exploitation. There is an enormous number of children that the country has to take care of. While articulating its vision of progress, development and equity, India has expressed its recognition of the fact that when its children are educated, healthy, happy and have access to opportunities, they are the countrys greatest human resource. Archives of Indian Psychiatry 8(2) October 2007
Critical Concerns:
Every fifth child in the world lives in India Every third malnourished child in the world lives in India Every second Indian child is underweight Three out of four children in India are anaemic Every second new born has reduced learning capacity due to iodine deficiency Decline in female/male ratio is maximum in 0-6 years: 927 females per 1000 males Birth registration is just 62% (RGI-2004) Retention rate at Primary level is 71.01% (Elementary Education in India Progress towards UEE NUEPA Flash Statistics DISE 2005-2006) Girls enrolment in schools at primary level is 47.79% (Elementary Education in India Progress towards UEE NUEPA Flash Statistics DISE 20052006) 1104 lakh child labour in the country (SRO 2000) IMR is as high as 58 per 1000 live births (SRS2005) MMR is equally high at 301 per 100,000 live births (SRS, 2001-03) Children born with low birth weight are 46% (NFHS-III) Children under 3 with anemia are 79% (NFHS-III)
Immunization coverage is very low (polio -78.2%, measles-58.8%, DPT-55.3%, BCG-78% (NFHS-III) Growth in Literacy: The literacy rate in 2001 has been recorded at 64.84% as against 52.21% in 1991. The 12.63 percentage points increase in the literacy rate during the period is the highest increase in any decade. There has been a significant decline in the absolute number of illiterates from 328.88 million in 1991 to 304 million in 2001. This has also been accompanied by a narrowing of the gap in male-female literacy rate from 24.84% in 1991 to 21.59% in 2001 as female literacy recorded an increase of 14.38 percentage points i.e. from 39.29% to 53.67% as compared to male literacy which recorded an increase of 11.13 percentage points i.e. from 64.13% to 75.26%. Besides, the urban-rural literacy differential has also decreased during the period. All States have registered an increase in literacy rates and 60% male literacy has been achieved in all states except Bihar. Inter-state and intra-state disparities still continue, although the gap between the educationally advanced and backward states has been narrowing over the years. 21
P. C. Shastri : Child And Law Illiteracy Size 2001 Census As a result of tremendous efforts on educational front and slight decline in the growth rate of population, the number of illiterates during the decade 1991-2001 came down from 329 millions in 1991 to 304 millions in 2001. NLM Achievements: Definition of Child :According to WHO child is defined as a young person upto the age of 18 years. Convention on the Rights of the Child (CRC) 1989, follow the same age criterion. Chronological age as a criterion to define child and adolescent can never do justice to these group of population who are growing and has special developmental needs and problems. But paediatrics department and other National and International Funding Agencies have cut off age as 12 years. Census in India had Child defined as an individual of 14 years or below. Childrens labour law gives the borderline as 16 years. Juvenile justice has age limit for male child as 16 years and female child as 21 years. The marriage act gives minimum age requirement for girls as 18 years & boys as 21 years. Different policies and program define the adolescence age group differently. For example adolescent in the draft youth policy have been defined as the age group between 13 and 19 years; under ICDS adolescent girls are considered to be between 11-18 years; the constitution of India and Labour laws of the country consider people upto the age of 14 years as children: whereas the Reproductive and Child Health program mentions adolescents as being between 1019 years of age. Internationally and as is with most UN agencies like WHO, UNICEF, UNFPA etc. the age group of 10-19 years is considered to be the age group of adolescents. It is observed that the age limit of the adolescents have been fixed differently under different programs keeping in view the objectives of the policy/ program. Age as a criterion for defining child may lead to quite confused and complex situation when it comes to child and various legal situations. Some of the overlapping areas which contradict and confuse are individuals working with different groups of children in need of special care. It is, therefore, very difficult to define a child with age as the criterion. It will need considerable concept clarity to define a child as a future citizen, a person, a partner and a parent; a responsible adult in any physical, mental, social and moral role-play. The Nations children are a supremely important asset. Their nurture and solitude are our responsibility. Childrens programmes, should find a prominent part in our national plans for the development of human resources, so that our children grow up to become responsible citizens. Equal opportunities for development to all children during the period of growth should be our aim, for this would serve our larger purpose of reducing inequality and ensuring social justice. It shall be the policy of the state to provide the adequate services to children, both before and after birth and through the period of growth to ensure their Archives of Indian Psychiatry 8(2) October 2007
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The literacy rate in 2001 has been recorded at 64.84% as against 52.21% in 1991. The 12.63 percentage points increase in the literacy rate during the period is the highest increase in any decade. 20.35 million persons have been made literate so far. Rate of growth is more in rural areas than in urban areas. The gap in male-female literacy rate has decreased from 24.84% in 1991 census to 21.59% in 2001. Female literacy increased by 14.38% i.e. from 39.3% to 53.67% whereas male literacy increased by 11.13% i.e. from 64.13% to 75.26% during the last decade. Gender equity and womens empowerment is also visible as about 60% of participants and beneficiaries are women. During 1991-2001 the population in 7+age group increased by 171.6 million while 203.6 million additional persons became literate during that period. All the States and union territories without exception have shown increase in literacy rates during 1991-2001. In all states and union territories, the male literacy rate is now over 60%. Kerala continues to have the highest literacy rate of 90.86% and Bihar has the lowest literacy rate of 47.00% Significant decline in absolute number of nonliterates from 328.88 million in 1991 to 304 million in 2001. Out of the total 600 districts in the country, 597 districts have been covered by NLM under literacy programme. Of these 101 districts are under TLC,171 are under PLP and 325 are under Continuing Education. Jan Shikshan Sansthans have been set up in the current year. One new SRC was set up in Chattisgarh and three SRCs viz Kerala, Karnataka and Uttarakhand were upgraded from Category B to Category A.
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Criminal Responsibility
Not below 7 years May be between 7-12 years 12-18 years depending on legal agencies and situations 12 18 18 18 years for operation years to make will years sell property years serve on jury
Consent
Assent Confidentiality Kidnapping Abduction Independence from lawful guardian
Below the age of 18 years Must after the age of 13 years 10 years Boys - 16years Girls - 18years Girls - 21years (foreign countries) 15 Yrs- marriage with consent 16 yrs- any other girl with consent 21 yrs Foreign national with consent Newborn 8 weeks to full term 18 years 25 years no age limit
Rape
InfanticideFoeticide
Employment For responsible post Witness
full physical, social and mental development. States shall progressively increase the scope of such services so that, within a reasonable time, all children in the country enjoy optimum condition for their balanced growth. I am sure 60 years is a reasonable time. It is high time that all children in the country enjoy optimum conditions for their balanced growth, development and quality of life. The UN Secretary Generals study on violence against children has given the following overview of the situation of abuse and violence against children across the globe:
An estimated 150 million girls and 73 million boys under 18 have experienced forced sexual intercourse or other forms of sexual violence involving physical contact. UNICEF estimates that in sub-Saharan Africa, Egypt and Sudan, 3 million girls and women are subjected to FGM every year. ILO estimates that 218 million children were involved in child labour in 2004, of whom 126 million were engaged in hazardous work. Estimates from 2000 suggest that 5.7 million were in forced or bonded labour, (no sample survey in India till 2006) 1.8 million in prostitution and pornography and 1.2 million were victims of trafficking.
WHO estimates that almost 53,000 child deaths in 2002 were due to child homicide. In the Global School-Based Student Health Survey carried out in a wide range of developing countries, between 20% and 65% of school going children reported having been verbally or physically bullied in school in the previous 30 days. Similar rates of bullying have been found in industrialised countries.
Only 2.4% of the worlds children are legally protected from corporal punishment in all settings. The National Policy for Children, 1974, declared children to be a supreme national asset. It pledged measures to secure and safeguard all their needs, 23

P. C. Shastri : Child And Law declaring that this could be done by making wise use of available national resources. Unfortunately, ten successive Five Year Plans have not allocated adequate resources to meet the needs of our children. An exercise on child budgeting carried out by the Ministry of Women and Child Development revealed that total expenditure on children in 2005-2006 in health, education, development and protection together amounted to a mere 3.86%, rising to 4.91% in 2006-07. However, the share of resources for child protection was abysmally low at 0.034% in 2005-06 and remained the same in 2006-07. 90% of the budgeted fund to go to staff and only 10% is spent on the child. Available resources have also not been utilized effectively for achieving outcomes for children. As a result, the status and condition of children have remained far from secure. Harmful traditional practices like child marriage, caste system, discrimination against the girl child, child labour and Devadasi tradition, impact negatively on children and increase their vulnerability to abuse and neglect. Lack of adequate nutrition, poor access to medical and educational facilities, migration from rural to urban areas leading to rise in urban poverty, children on the streets and child beggars, all result in breakdown of families. These increase the vulnerabilities of children and expose them to situations of abuse and exploitation. According to the report published in 2005 on Trafficking of Women and Children in India, 44,476 children were reported missing in India, out of which 11,008 children continued to remain untraced. India, being a major source and destination country for trafficked children from within India and adjoining countries has, by conservative estimates, three to five lakh girl children in commercial sex and organized prostitution. Status of Indias Children Child Survival and Child Health 2.5 million children die in India every year, accounting for one in five deaths in the world, with girls being 50% more likely to die . One out of 16 children die before they attain one year of age, and one out of 11 die before they attain five years of age. India accounts for 35% of the developing worlds low birth weight babies and 40% of child malnutrition in developing countries, one of the highest levels in the world. Although Indias neo-natal mortality rate declined in the 1990s from 69 per 1000 live births in 1980 to 53 per 1000 live births in 1990, it remained static, dropping only four points from 48 to 44 per 1000 live births between 1995 and 2000. The 2001 Census data and other studies illustrate the terrible impact of sex selection in India over the last few decades. The child sex ratio (0-6 years) declined from 945 girls to 1000 boys in 1991 to 927 in the 2001 Census. Around 80% of the total 600 districts in the country registered a decline in the child sex ratio between 1991 24
and 2001. About 35% of the districts registered child sex ratios below the national average of 927 females per 1000 males. In the 1991 Census, there was only one district with a sex ratio below 850, but in the 2001 Census, there were 49 such districts. This is a dangerous trend and an alarming phenomenon which should be arrested at the earliest. There are many such disturbing figures, for e.g. India has the second highest national total of persons living with HIV/AIDS after the Republic of South Africa. According to National Aids Control Organization (NACO), there were an estimated 0.55 lakh HIV infected 0-14 year old children in India in 2003. UNAIDS, however, puts this figure at 0.16 million children. According to the 2001 Census report, amongst all persons living with disabilities, 35.9% were children and young adults in the 0-19 age group. Three out of five children in the age group of 0-9 years have been reported to be visually impaired. Movement disability has the highest proportion (33.2%) in the age group of 10-19 years. This is largely true in case of mental disability also. Child Development The population of children aged 0-6 years is 16.4 crores as per the 2001 Census. According to a UNESCO report, however, of the total child population, 2.07 crores (6%) are infants below one year; 4.17 crores (12%) are toddlers in the age group 1-2 years; 7.73 crores (22.2%) are pre-schoolers in the age group 3-5 years. The report highlights that only 29% of pre-primary age children are enrolled in educational institutions in India. Services under the ICDS scheme covered only 3.41 crore children in the age group 0-6 years as in March 2004, which is around 22% of the total children in that age group. Supplementary nutrition too was being provided to 3.4 crore children, as against 16 crore children. Of these, 53% were reported to be under-nourished. Child Protection While on one hand girls are being killed even before they are born, on the other hand children who are born and survive suffer from a number of violations. The worlds highest number of working children is in India. To add to this, India has the worlds largest number of sexually abused children, with a child below 16 years raped every 155th minute, a child below 10 every 13th hour and one in every 10 children sexually abused at any point of time. The National Crime Records Bureau (NCRB) reported 14,975 cases of various crimes against children in 2005. Most subtle forms of violence against children such as child marriage, economic exploitation, practices like the Devadasi tradition of dedicating young girls to gods and goddesses, genital mutilation in some parts of the country are often rationalized on grounds of culture and tradition. Physical and psychological punishments take place in the name of Archives of Indian Psychiatry 8(2) October 2007
P. C. Shastri : Child And Law disciplining children and are culturally accepted. Forced evictions, displacement due to development projects, war and conflict, communal riots, natural disasters - all of these take their own toll on children. Children also stand worst affected by HIV/AIDS. Even those who have remained within the protective net, stand at the risk of falling out of it. Children in name of protection are kept in custody in custodial homes and the adult offender who is legally a criminal is free in the society to commit more crimes against children in the society. Child Participation Children in most sections of Indian society are traditionally and conventionally not consulted about matters and decisions affecting their lives. In the family and household, the neighbourhood and wider community, in school or in work place, and across the settings of social and cultural life, childrens views are mostly not given much importance. If they do speak out, they are not normally heard. The imposition of restrictive norms is especially true for a girl child. This limits childrens access to information and freedom to choose, and often to the possibility of seeking help outside their immediate circle. Although there is a dearth of data on the nature and magnitude of the incidence of child abuse in India, data on offences against children reported by the National Crime Records Bureau (NCRB) is the only authentic source to estimate the number of children in abusive situations. It is important to note here that the NCRB data is only indicative in nature as it is based on the reported cases. It is also an accepted fact that the majority of cases of child abuse go un-reported. Between 2002 and 2005 there was a steep rise in the total number of crimes against children. In 2002, 5972 cases were registered as against 14975 cases registered in 2005. Incidence of kidnapping and abduction of children were around 2322 in 2002 and 2571 in 2003, which rose to 3196 and 3518 in 2004 and 2005 respectively. It is difficult to interpret the findings because many factors might influence such registered records. It may be improved awareness, more reporting and/or increase in incidence. Although the reported number of cases of procurement of minor girls has decreased by 9.3% in 2005 compared to 2004, media and other reports indicate that the unofficial number is much higher. Reported cases of child rape, one of the worst forms of sexual abuse, have increased in number between 2004 and 2005, from 3542 cases to 4026 respectively, indicating an increase of 13.7%. In India the problem of child abuse has not received enough attention. There have been sporadic efforts to understand and address the problem. However, child abuse is prevalent in India as in many other countries and there is a need to understand its dimensions and complexities. Archives of Indian Psychiatry 8(2) October 2007
The Indian society, like most societies across the world, is patriarchal in structure where the chain of command is definite and inviolable. In such power structures parents, both fathers and mothers, consider their children as their property and assume a freedom to treat them as they like. Thus, not only do parents and teachers adopt harsh methods of disciplining children, there is also little opposition to this harshness. The underlying belief is that physical punishment encourages discipline in children and is for their betterment in the long-run. There is enough scientific proof to the contrary and evidence suggests that sometimes it is parents inability to raise their children, and their frustrations, that find a manifestation in the form of beating them or causing other physical harm. Severe physical maltreatment also takes place outside family situations and the most common and known forms of it are corporal punishment in schools and physical abuse at work place. Working children have a high probability of being abused by their employer or supervisor. The reasons could be dependence of the child on the employer and the vulnerability of the child, who is a soft and available target for the anger and frustrations of the employer. The same goes with teachers in schools and every other person resorting to physical abuse of children. Physical abuse of children takes place across cultures, societies, economic and social strata. It is seen largely in homes where frustrations are high; parents have poor parenting skills and have little or no self control; where there are visible marital problems, substance abuse, and domestic violence and so on. Children are physically small, vulnerable and totally dependent on parents. A child is dependent on parents for all his/her needs; be it food, shelter, protection, healthcare, love and care or education. He/she is constantly seeking approbation and positive reinforcement of his/her own value from the parent/caregiver. Thus, constant physical abuse can be extremely demoralizing for the child, no matter what the provocation. It is important to understand that the cycle of abuse is self-perpetrating. A child who has faced severe forms of abuse during childhood is likely to become an abuser in later years. In India there is a widespread belief that the family is ultimate and supremely capable of looking into the best interests of the child. In fact interference in anyones family matters is perceived as infringement on the privacy of the family. As a result, a lot of abuse remains hidden within the family and remains unreported. The overall analysis of physical abuse of children in schools revealed some significant findings: 1. 65% of children reported corporal punishment in schools. 2. Older children were beaten more in schools as 25
P. C. Shastri : Child And Law compared to younger ones. Very high percentage of corporal punishment was reported in government and municipal schools. 4. NGO run schools also reported high percentage of corporal punishment. In India, the traditional approach towards care of children in difficult circumstances has been institutionalization. This practice started with the realization of the fact that there were a large number of children without parental care, vulnerable and in need of care and protection. State interventions resulted in setting up of state run institutions to provide food, shelter, clothing and education to children who were not living in the family environment. These institutions were visualized as comprehensive child care units to cater to the needs of children in difficult circumstances. However, the standards of care in these institutions have always been a cause of concern. There is enough evidence to establish that institutionalization is not in the best interest of children and incidences of child abuse and neglect within these institutions are common. In fact, such incidents have been reported by the media from time to time. Fundamental rights have been made subject to a law to be made by parliament. Do they intent to make rights into law? No government in last 60 years has made these fundamental rights into a law. We need mass movement and awareness campaigns to ensure that all rights are made into laws and implemented at the earliest. If we want to create wonderful tomorrow for our children we have to do it today as otherwise child has no tomorrow. Juvenile justice board has not been formed in various states in spite of last date being August 2007. Juvenile Justice Act 1999 and 2000 is yet to be implemented. There is no law and will to see that laws are implemented at the earliest with the utmost sincerity. At present various settings where children are under judicial custody, are worst than jails for the criminals. One may call it remand home, rescue home, observation home, vocational training institutes, beggars home or destitute home; but in many cases children there are ill treated, abused and poorly cared for. It invariably results in traumatising the child further, in more criminalization and deterioration of childs behaviour. Such institutions have no physical, psychological, social, emotional and educational environment to promote childs growth and development or welfare. The Law Ministry has retuned the proposed offences against children (prevention) Bill 2005 Women Child Development (WCD) Ministry saying that it cannot be passed in its present form. According to officials from WCD ministry the proposed law has specific sections dealing with various offences against children including 3. sell/ transfer, sexual assault, sexual / physical / emotional abuse, commercial and sexual exploitation, child pornography, grooming for sexual purpose which have not been covered under the IPC Section 354, 375 and 377. An offence such as girl child neglect and trafficking which has not been covered under any law has been brought under the purview of the proposed law. The proposed law also has provision against incest, corporal punishment, bullying and economic exploitation. This law makes it punishable and proposes maximum penalty for child abuse as 7 years in prison. However, we need full fledged law for children. At present we have inadequate I.P.C. sections which do not protect children in various situations and also fails to punish the offenders. Girl child is being hunted and murdered in the womb and outside the womb. In Chambal area of Madhya Pradesh sex ratio is 400 females to 1000 males. Villages in Chambal area become a girl childs grave. Some of the villages have never seen a Baraat in many years. There are some villages in Rajasthan that has not seen a single female born since independence. Compared to the examples cited above, all India child sex ratio is 927 per 1000, 917 per 1000 in Maharashtra and 898 per 1000 in city of Mumbai. 49.9% of female deaths in rural Rajasthan are of girls below 20 years of age. 42% of them die and never celebrate their fifth birthday. Hindi heartland Bimaru States of Uttar Pradesh, Madhya Pradesh and Chattisgarh are similarly placed. In Uattar Pradesh boys and girls from rural as well as urban have mortality rates of 50% before the age of 20 years (Bureau of Health Intelligence, Health Ministry 2006). The needs of children and our duties towards them have been expressed in the constitution. The resolution on a national policy of education, which has been adapted by Parliament, gives direction of state policy on educational needs of the children. We are also party to the U.N. declaration of the rights of the child. The goals set out in this document can reasonably be achieved by judicious and efficient use of available natural resources. As clinician, academician, therapist, jurist society and parent in particular do not know all the legal provision. Rights, benefits, concessions, relief in taxation, any other monetary privileges and benefits in finance and banking sector is not known to large majority of people, thus not getting the benefit of the existing facilities. Large numbers of clinicians do not know the confidentiality which is a must after the age of 13 years of age, in STDs, pregnancy, substance abuse and various mental health issues. Informed consent can be taken after 13 years of age after evaluation of patients ability to understand. Breeching an adolescents confidentiality is termed as justified paternalism. Treatment without parental consent will result in therapist sued for Archives of Indian Psychiatry 8(2) October 2007
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P. C. Shastri : Child And Law negligence, assault and battery. One can refer to IPS Section 87, 88, 89 and 92. In India only major (above 18 years) can give consent. While in United Kingdom valid age is 16 years for consent and in U.S.A. it is 14 years with adequate maturity. Large numbers of clinicians need to be well informed that consent before examination of medico-legal case is a must. Section 53 of Criminal Penal Code necessitates a criminal juvenile girl must be examined only by a female doctor. One needs to know few exceptions. In medical emergency the law implies automatic consent. Loco-parentis is defined as the consent given by the person in charge of the child at that time. Legally he or she is the locum guardian. Large number of legal and judicial issues in the justice system that deals with child and adolescent need to be understood as well as interpreted favourably to child and adolescent population. It is unfortunate that our country is signatory to all the rights of child and adolescent, but has not implemented any by converting the same into law in parliament. Existing law whether it is civil, criminal, educational, labour, marriage and protection of domestic violence act 2005 have not been practised. Implementation and success of judiciary can only be measured by effective implementation to the vulnerable group of child and adolescent population. Mental health Act, Juvenile Justice Act, Disability Act and National Trust need lot of clarity; rectification and implementation uniformly at all level both in rural and urban India. We need to transform. We have a long way to make up. Physical Abuse 1. Two out of every three children were physically abused. 55% were boys. 2. Over 50% children in all the 13 sample states were being subjected to one or the other form of physical abuse. 3. Out of those children physically abused in family situations, 88.6% were physically abused by parents. 4. 65% of school going children reported facing corporal punishment i.e. two out of three children were victims of corporal punishment. 5. 62% of the corporal punishment was in government and municipal schools. 6. The State of Andhra Pradesh, Assam, Bihar and Delhi have almost consistently reported higher rates of abuse in all forms as compared to other states. 7. Most children did not report the matter to anyone due to lack of redressal system in society. Parents, teachers and employers of these children who are supposed to protect provide and care are the abusers in most of the cases. 8. 50.2% children worked seven days a week. Sexual Abuse 1. 53.22% children reported having faced one or more forms of sexual abuse. 2. Andhra Pradesh, Assam, Bihar and Delhi reported the highest percentage of sexual abuse among both boys and girls. 3. 21.90% child respondents reported facing severe forms of sexual abuse and 50.76% other forms of sexual abuse. 4. Out of the child respondents, 5.69% reported being sexually assaulted. 5. Children in Assam, Andhra Pradesh, Bihar and Delhi reported the highest incidence of sexual assault. 6. Children on street, children at work and children in institutional care reported the highest incidence of sexual assault. 7. 50% abuses are persons known to the child or in a position of trust and responsibility. 8. Most children did not report the matter to anyone. How society is perceived by the child or adolescent is the key to communication. It is the attitudinal aspect of family and society which results in low percentage of reporting. This is a serious matter as these are the children at high risk, surrounded by abusers who are in position of trust and responsibility in the family. It makes punishing such abuser very difficult. Emotional Abuse and Girl Child Neglect 1. Every second child reported facing emotional abuse. 2. Equal percentage of both girls and boys reported facing emotional abuse. 3. In 83% of the cases parents were the abusers. 4. 48.4% of girls wished they were boys. The gravity of the situation demands that the issue of child abuse be placed on the national agenda. The Ministry on its part has taken measures such as the enabling legislation to establish the National and State Commissions for Protection of Rights of the Child, the Integrated Child Protection Scheme, the draft Offences against Children Bill etc. These are a few important steps to ensure protection of children of the country. But clearly, this will not be enough; the government, civil society and communities need to complement each other and work towards creating a protective environment for children. The momentum gained needs to enhance further discussion on the issue amongst all stakeholders and be translated into a movement to ensure protection of children of this country. Child abuse is a state of emotional, physical, economic and sexual maltreatment meted out to a person below the age of eighteen and is a globally prevalent phenomenon. However, in India, as in many other 27
Archives of Indian Psychiatry 8(2) October 2007 40053250

P. C. Shastri : Child And Law countries, there has been no understanding of the extent, magnitude and trends of the problem. The growing complexities of life and the dramatic changes brought about by socio-economic transitions in India have played a major role in increasing the vulnerability of children to various and newer forms of abuse. Child abuse has serious physical and psycho-social consequences which adversely affect the health and overall well-being of a child. According to WHO: Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the childs health, survival, development or dignity in the context of a relationship of responsibility, trust or power. Child abuse is a violation of the basic human rights of a child and is an outcome of a set of inter-related familial, social, psychological and economic factors. The problem of child abuse and human rights violations is one of the most critical matters on the international human rights agenda. In the Indian context, acceptance of child rights as primary inviolable rights is fairly recent, as is the universal understanding of it. Violation of childs right and abuse in India is highly complex and difficult problem to solve. Poverty, illiteracy, no home, no school, poor working conditions results in more exploitations and more abuse. Abused child becomes an adult abuser. This vicious cycle goes on. CONSTITUTION OF INDIA The Constitution of India recognizes the vulnerable position of children and their right to protection. Following the doctrine of protective discrimination, it guarantees in Article 15 special attention to children through necessary and special laws and policies that safeguard their rights. The right to equality, protection of life and personal liberty and the right against exploitation are enshrined in Articles 14, 15, 15(3), 19(1) (a), 21, 21(A), 23, 24, 39(e) 39(f) and reiterate Indias commitment to the protection, safety, security and well-being of all its people, including children. Article 14: The State shall not deny to any person equality before the law or the equal protection of the laws within the territory of India; Article 15: The State shall not discriminate against any citizen on grounds only of religion, race, caste, sex, place of birth or any of them; Article 15 (3): Nothing in this article shall prevent the State from making any special provision for women and children; Article 19(1) (a): All citizens shall have the right (a) to freedom of speech and expression; Article 21: Protection of life and personal liberty No person shall be deprived of his life or personal liberty 28
except according to procedure established by law; Article 21A: Free and compulsory education for all children of the age of 6 to 14 years; Article 23: Prohibition of traffic in human beings and forced labour - (1) Traffic in human beings and beggars and other similar forms of forced labour are prohibited and any contravention of this provision shall be an offence punishable in accordance with law; Article 24: Prohibition of employment of children in factories, etc. - No child below the age of fourteen years shall be employed to work in any factory or mine or engaged in any other hazardous employment; Article 39: The state shall, in particular, direct its policy towards securing: (e) that the health and strength of workers, men and women, and the tender age of children are not abused and that citizens are not forced by economic necessity to enter vocations unsuited to their age or strength; (f) that children are given opportunities and facilities to develop in a healthy manner and in conditions of freedom and dignity and that childhood and youth are protected against exploitation and against moral and material abandonment. INTERNATIONAL CONVENTIONS AND DECLARATIONS India is signatory to a number of international instruments and declarations pertaining to the rights of children to protection, security and dignity. It acceded to the United Nations Convention on the Rights of the Child (UN CRC) in 1992, reaffirming its earlier acceptance of the 1959 UN Declaration on the Rights of the Child, and is fully committed to implementation of all provisions of the UN CRC. In 2005, the Government of India accepted the two Optional Protocols to the UN CRC, addressing the involvement of children in armed conflict and the sale of children, child prostitution and child pornography. India is strengthening its national policy and measures to protect children from these dangerous forms of violence and exploitation. India is also a signatory to the International Conventions on Civil and Political Rights, and on Economic, Social and Cultural Rights which apply to the human rights of children as much as adults. Three important International Instruments for the protection of Child Rights that India is signatory to, are: Convention on the Rights of the Child (CRC) adopted by the UN General Assembly in 1989, is the widely accepted UN instrument ratified by most of the developed as well as developing countries, including India. The Convention prescribes standards to be adhered to by all state parties in securing the best interest of the child and outlines the fundamental rights of children,

P. C. Shastri : Child And Law including the right to be protected from economic exploitation and harmful work, from all forms of sexual exploitation and abuse and from physical or mental violence, as well as ensuring that children will not be separated from their families against their will. Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) is also applicable to girls under 18 years of age. Article 16.2 of the Convention lays special emphasis on the prevention of child marriages and states that the betrothal and marriage of a child shall have no legal effect and that legislative action shall be taken by States to specify a minimum age for marriage. SAARC Convention on Prevention and Combating Trafficking in Women and Children for Prostitution emphasizes that the evil of trafficking in women and children for the purpose of prostitution is incompatible with the dignity and honour of human beings and is a violation of basic human rights of women and children. Child Rights and Millennium Development Goals (MDGs) The Government of India is addressing the protection rights of children in India within the framework of the MDGs which India has committed to achieve by 2015. The Mid-Term appraisal report on the 10th Plan found that India is far from achieving the MDGs as the outcomes on most of the goals were off-track in 2005. National Policies And Legislations Addressing Child Rights The Fundamental Rights and Directive Principles of the Indian Constitution provide the framework for child rights. Several laws and national policies have been framed to implement the commitment to child rights. National policies The major policies and legislations formulated in the country to ensure child rights and improvement in their status include: 1 National Policy for Children, 1974 2 National Policy on Education, 1986 3 National Policy on Child Labour, 1987 4 National Nutrition Policy, 1993 5 Report of the Committee on Prostitution, Child Prostitutes and Children of Prostitutes and Plan of Action to Combat Trafficking and Commercial Sexual Exploitation of Women and Children, 1998 6 National Health Policy, 2002 7 National Charter for Children, 2004 8 National Plan of Action for Children, 2005 The guiding Principals of National Plan of Action for Children (NPAC, 2005)
To address issues of discrimination emanating from biases of gender, class, caste, race, religion and legal status in order to ensure equality To accord utmost priority to the most disadvantaged, poorest of the poor and the least served child in all policy and programme interventions
To regard the child as an asset and a person with human rights
To recognize the diverse stages and settings of childhood, and address the needs of each, providing all children the entitlements that fulfill their rights and meet their needs in each situation. National legislations National legislations for protection of child rights in the country are: 1 Guardian and Wards Act, 1890 2 Factories Act ,1954 3 Hindu Adoption and Maintenance Act, 1956 4 Probation of Offenders Act, 1958 5 Bombay Prevention of Begging Act, 1959 6 Orphanages and Other Charitable Homes (Supervision and Control) Act, 1960 7 Bonded Labour System (Abolition) Act, 1976 8 Immoral Traffic Prevention Act, 1986 9 Child Labour (Prohibition and Regulation) Act,1986 10 Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act, 1987 11 Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 12 Persons with Disabilities (Equal Protection of Rights and Full Participation) Act, 2000 13 Juvenile Justice (Care and Protection of Children) Act, 2000 14 Commission for Protection of the Rights of the Child Act, 2005 15 Prohibition of Child Marriage Act 2006 Some of the important legislations are discussed below. Under each Act relevant sections have been enumerated: (i) The Indian Penal Code a. Foeticide (Sections 315 and 316) b. Infanticide (Section 315) c. Abetment of Suicide: Abetment to commit suicide of minor (Section 305) d. Exposure and Abandonment: Crime against children by parents or others to expose or to leave them with the intention of abandonment (Section 317) e. Kidnapping and Abduction: Kidnapping for extortion (Section 360) Kidnapping from lawful guardianship (Section 29

P. C. Shastri : Child And Law 361) Kidnapping for ransom (Section 363 read with Section 384), Kidnapping for camel racing etc. (Section 363) Kidnapping for begging (Section 363-A) Kidnapping to compel for marriage (Section 366) Kidnapping for slavery etc. (Section 367) Kidnapping for stealing from its person: under 10 years of age only (Section 369) Abduction (Section 362) f. Procurement of minor girls by inducement or by force to seduce or have illicit intercourse (Section 366-A) g. Selling of girls for prostitution (Section 372) h. Buying of girls for prostitution (Section 373) i. Rape (Section 376) j. Unnatural Sex (Section 377). (ii) The Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 This is an Act for the regulation of the use of prenatal diagnostic techniques for the purpose of detecting genetic or metabolic disorders, chromosomal abnormalities or certain congenital malformations or sex-linked disorders, and for the prevention of misuse of such techniques for the purpose of prenatal sex determination leading to female foeticide and for matters connected therewith or incidental thereto. Diagnostic centres run and do what is needed like many female foeticide after sex determination uniformly all over the country. Where such facility is not available female infanticide is a practice with no legal agency intervening or investigating. (iii) The Juvenile Justice (Care and Protection of Children) Act, 2000 The Juvenile Justice (Care and Protection of Children) Act, 2000 is a comprehensive legislation that provides for proper care, protection and treatment of children in conflict with law and children in need of care and protection by catering to their development needs, and by adopting a child friendly approach in the adjudication and disposition of matters in the best interest of children and for their ultimate rehabilitation through various institutions established under the Act. It conforms to the UN Convention on the Rights of the Child, the UN Standard Minimum Rules for the Administration of Juvenile Justice (The Beijing Rules) 1985, the UN Rules for the Protection of Juveniles Deprived of their Liberty and all other relevant national and international instruments. It prescribes a uniform age of 18 years, below which both boys and girls are to be treated as children. A clear distinction has been made in this Act between the juvenile offender and the neglected child. It also aims to 30
offer a juvenile or a child increased access to justice by establishing Juvenile Justice Boards and Child Welfare Committees. The Act has laid special emphasis on rehabilitation and social integration of the children and has provided for institutional and non-institutional measures for care and protection of children. The noninstitutional alternatives include adoption, foster care, sponsorship, and after care. Need for such care is very high but provisions are scanty and few. When on demand no one is there to address these childrens problem that are in conflict with the law. The Integrated Child Protection Scheme (IPCS) A Centrally Sponsored Scheme of Government Civil Society Partnership Background: In the light of its expanded mandate, the Ministry of Women and Child Development views Child Protection as an essential component of the countrys strategy to place Development of the child at the centre of the Eleventh Plan, as envisaged in the Approach Paper to the Eleventh Plan. The Integrated Child Protection Scheme (ICPS) is, therefore, proposed by the Ministry of Women and Child Development as a centrally sponsored scheme to address the issue of child protection and build a protective environment for children through Government-Civil Society Partnership. Why ICPS? Child protection is integrally linked to every other right of the child. Failure to ensure childrens right to protection adversely affects all other rights of the child. Child protection is also closely linked to the achievement of the Millennium Development Goals (MDGs) and policy makers have failed to see this connection or chosen to overlook it. Most existing mechanisms on child protection cater to post-harm situations. Preventive measures to reduce vulnerability of children and their families and to prevent children from falling out of the protective net are completely lacking in both the approach to child protection as well as programmatic intervention. There are multiple vertical schemes for child protection scattered under different Ministries / Departments- for example, the Labour Ministry is responsible for child labour elimination programmes, Ministry of Women and Child Development takes care of juvenile justice, child trafficking and adoption related matters, Ministry of Health and Family Welfare looks into the implementation of PC & PNDT Act to check female foeticide. There are glaring gaps in the infrastructure, set up and outreach services for children, as they exist now. These include: Archives of Indian Psychiatry 8(2) October 2007
P. C. Shastri : Child And Law Poor planning and coordination: prevention has never been part of planning for child protection. Lack of lateral linkages with other sectors for ensuring prevention of violence, abuse or any other harm to children and protection of those outside the safety net has failed to ensure social justice. Low coverage: numbers of children outside the safety net with no support and services is ever increasing and lack of systematic and comprehensive mapping of children in need of care and protection or of the services available for them at the district / city / state level results in low and poor coverage. Poor Infrastructure: the minimal government structure that exists is rigid and a lot of time and energy goes in maintaining the structure itself rather than concentrating on programme outcomes. Moreover even the infrastructure prescribed by law is not in place, for example, JJBs and CWCs under the Juvenile Justice Act are lacking, shelter and institutional care facilities are also highly inadequate. Inadequate Resources: child protection constitutes only 0.034 percent of the total Union Budget. Not only is allocation of resources poor in terms of geographical spread, even the utilization of resources is uneven. Serious Service Gaps: there is a lack of services to deal with all categories of children in need of care and protection and supervision, monitoring and evaluation of programmes and services are weak. Child protection is not a priority in the States either. Poor understanding of child rights and lack of child friendly approach affect both planning and service delivery. Objectives: The ICPS brings together multiple vertical schemes under one comprehensive child protection scheme, combining existing child protection schemes of the Ministry and integrating interventions for protecting children and preventing harm. The ICPS therefore broadly aims at: (i) (ii) (iii) (iv) (v) Institutionalising essential strengthening structures. Enhancing capacities at all levels. Creating database and knowledge base for child protection services. Strengthening child protection at family and community level. services and levels: Programme Components: 1) Emergency Outreach Service through Childline 2) Drop-in Shelters for Marginalized Children 3) Non Institution Based Family Care a) Adoption b) Foster Care c) Sponsorship d) After-Care e) Cradle Baby Reception Centre 4) Institutional Services a) Shelter Homes b) Childrens Homes c) Observation Homes d) Special Homes e) Specialised services for Children with special needs 5) General Grant-in-Aid for Need Based/Innovative Interventions 6) Statutory Support Services: a) Juvenile Justice Boards b) Child Welfare Committees c) Special Juvenile Police Units 7) Training and Capacity Building 8) Strengthening the Knowledge-base 9) Advocacy and Communication 10) Monitoring and Evaluation Service Delivery Structure 1. State Child Protection Unit (SCPU) 2. State Adoption Resource Agency (SARA) 3. District Child Protection Unit (DCPU) There is very little research on physical abuse in India. A study of Physical and Sexual Abuse and Behavioural Problems amongst boys in a Child Observation Home in Delhi was conducted by Dr. Deepti Pagare (Community Medicine), Maulana Azad Medical College, New Delhi, as part of her doctoral dissertation. The study revealed the following: About three-fourth (76.7%) of subjects reported physical abuse. On clinical examination, among the physically abused children (n=145) physical signs were seen in 49.7% and behavioural signs in 22.8%. The most common perpetrators of physical abuse were fathers (55.2%) followed by policemen (29.7%). Physical abuse was found to be significantly associated with domestic violence, substance use in 31
Ensuring appropriate inter-sectoral response at all levels. The scheme proposes to achieve the abovementioned objectives through effective implementation of child protection services at district, state and regional Archives of Indian Psychiatry 8(2) October 2007
P. C. Shastri : Child And Law family, step parent, substance use by child, running away from home and working status. A research study in West Bengal conducted by Save the Children and Tulir in 2006 among child domestic workers revealed that: Almost 70% of the child domestic workers had been physically abused. In 41.5% cases the abuser was from the employers family. 46.6% of the children had faced severe abuse that left them with bodily injuries of which 25.3% reported that they were cut or bruised as a result of the violence. About 25% of the child domestic workers reported that the abuse was still happening with them. 1. Out of 12,447 child respondents, an overwhelming majority (69.0%) reported physical abuse in one or more situations. 2. Children faced high level of physical abuse in families. 3. In the overall percentage there seemed to be not much difference in physical abuse being faced by girls and boys. 4. Out of those children physically abused in family environment, around 89% were physically abused by parents. 5. In different age categories, the higher percentage of physical abuse was reported among younger children (5-12 years) Physical abuse of children in families takes place when parents or other family members physically injure or inflict serious physical pain on the child. This includes hitting with hands or fists, hitting with objects (wooden, plastic or metallic objects), burning, shaking infants, stabbing and so on. Such hitting, beating, burning etc. is not often perceived as physical abuse and takes place on the pretext of disciplinary practices that begin with spanking or occasional hitting, and transgress into extreme forms causing permanent physical damage to the child. Parents / caregivers and people in positions of trust and responsibility, who cause serious physical damage to their own child or to children in their care, go against the legal, social, and moral standards of society. Under the Child Labour (Prohibition and Regulation) Act 1986, engagement of children below the age of 14 years in hazardous occupations has been declared illegal. However, there is debate whether children below the age of 18 should be employed at all and a large section of people feel that children who do not go to school and are employed in some way are in potentially hazardous situations. Even in those occupations where the law allows children to be employed, the conditions under which these children work and the hours they are made to work are exploitative and 32
often inhuman. The overall analysis of physical abuse of working children revealed some significant findings: 1. Boys and girls were being equally abused 2. 50% of the children worked seven days a week 3. 56.38% of the children were working in the illegal/ hazardous occupations 4. 65% of the children were working because of parental pressure and 76% of them handed over their earnings to their parents 5. More than 80% of child domestic workers were girls 6. More than 80% of children working in tea kiosks and restaurants were boys 7. More than 80% of children working in bidi rolling were girls The overall analysis of physical abuse of street children revealed some significant findings: Boys and girls were being equally abused 66.8% of the street children reported physical abuse 65.9% of the street children lived with their families on the streets. General Recommendations 1) Policy and Legislation: The present National Policy on Children 1974 needs revision and there is a clear and established need for a separate National Child Protection Policy. In addition, every state should set up a State Commission for the Protection of Rights of the Child and formulate Plans of Action for Child Protection at the district and state levels. There is also a clear and established need for a National Legislation to deal with child abuse. The proposed legislation should address all forms of sexual abuse including commercial sexual exploitation, child pornography and grooming for sexual purpose. It should also deal with physical abuse including corporal punishment and bullying, economic exploitation of children, trafficking of children and the sale and transfer of children. The legislation should also look at mechanisms of reporting and persons responsible for reporting. This must be seen in the context of the fact that more than 70% of the child respondents do not report the matter of sexual abuse to anyone. It has also very clearly emerged that the largest percentage of abusers are persons within the family or persons in position of trust and authority. The legislation should address such issues also. 2) Protocols: In order to enhance the standards of care and build a protective environment for children in the country, there is a need to develop standard protocols on child protection mechanisms at the district, block and village levels, defining roles and responsibilities of each individual and agency. Such protocols should also lay Archives of Indian Psychiatry 8(2) October 2007
P. C. Shastri : Child And Law down standards and procedures for effective child protection service delivery including preventive, statutory, care and rehabilitation services for children. An effective community based monitoring mechanism needs to be put in place to ensure accountability at various levels. Monitoring should be based on indicators of performance such as quality of services and levels of child friendliness. 3) Scheme on Child Protection: So far child protection has been dealt with in a piecemeal and dilatory way with allocation of minimum resources reaching out to a miniscule numbers of children in difficult circumstances. The results of the study point to the need for a national scheme. Such a scheme should identify vulnerable families and children, prevent vulnerabilities and provide services to those in need. The scheme should strengthen statutory support services provided under the Juvenile Justice (Care and Protection of Children) Act 2000 for children in need of care and protection and children in conflict with law. With the allocation of adequate financial and human resources, the scheme should help create a protective environment for children through strong service delivery mechanisms, outreach services and effective interventions. 4) Outreach and Support Services: The study has revealed that the majority of abuse cases take place within the family environment, the perpetrators being close family relatives. A child who has been abused or continues to be in an abusive situation, needs a variety of services, including professional help in the form of trauma counseling, medical treatment, police intervention and legal support. Such a system should be established under the scheme on child protection. Further, the existing Childline service providing emergency outreach services to children in difficult circumstances should be expanded. Migration and rapid urbanization have forced a very large number of children onto the streets. Such children survive by begging, working, scavenging, rag picking, etc. It is essential to provide outreach services to these children through bridge education, night shelters and vocational skills, so as to get them off the streets, reduce their vulnerability and enable them to sustain themselves. 5) Tracking Missing Children: Children go missing for a number of different reasons. Difficult and abuse situations at home often force children to run away; economic compulsions make them move to urban and semi-urban areas in search of a living; and sometimes they are trafficked for domestic work, other forms of labour or commercial sexual exploitation. Annually, large numbers of children go missing and there is little attempt to track them or trace them. Such children are most vulnerable to all forms of abuse and exploitation. Not only should they be tracked Archives of Indian Psychiatry 8(2) October 2007
but existing mechanisms for their rescue, rehabilitation, repatriation and reintegration should be reviewed and strengthened while keeping in view the best interests of the child. Children run away from psychologically and/or physically broken families. Total family unit needs care and treatment so that child will develop and prosper tomorrow. 6) Shared Responsibility: Child protection is a shared responsibility, and for any intervention to be effective there should be a synergy between efforts being made by different stakeholders to address the issues. There is a need to create a mechanism that will make such a synergy possible. These may include child protection mechanisms at village, block, district and state levels which involve parents, elected representatives of urban and rural local bodies, teachers, anganwadi workers, medical practitioners, police and social workers and responsible members of public among others. 7) Capacity Building: All the above recommendations regarding formulation of a new policy, legislation, scheme and strengthening of the service delivery mechanism, assume the creation of a cadre of trained personnel, sensitized to child rights and protection of children. In order to create this cadre, in the first instance, schools of social work and universities should offer specialized courses on child rights, protection and counselling. Further, child rights and protection issues should be integrated into the curricula of administrative institutes, police training academies, law colleges, medical colleges, teacher training schools, etc. so that the professionals passing out of these institutions have both the sensitivity and the knowledge to deal with these issues. Capacity enhancement and skill up-gradation of those who are already working in this sector are also essential. Further, there is a need to regularly up-grade the skills and capabilities of the civil society organizations. Parents and caregivers are primarily responsible and accountable for the safety and security of the children in their care. The results of the study suggest that somewhere parents have not lived up to these expectations. Therefore, there is a need to enhance parenting skills, knowledge of the subject and sensitivity, which will help them to handle situations of child sexual abuse. Life skill education of children to enhance their knowledge and capacity to deal with abuse is essential. It is proposed that this should become an integral part of the school curriculum. 8) Gender Equity: Equity is possible if social norms ensure that the girl child lives in a non-abusive environment in which she 33
P. C. Shastri : Child And Law is cared for and respected. Discrimination of girls results in their lower enrollment in schools, higher levels of malnutrition, trafficking of girls for sexual exploitation, child marriage and their non-participation in decisionmaking in the family etc. These imbalances need to be addressed by bringing about attitudinal changes in people regarding the value of the girl child. Empowerment of adolescent girls should be done by making them aware of their rights, orientating them on the subject of abuse, instilling life skills including knowledge of childbirth and child rearing practices, HIV & AIDS and personal hygiene among others. The adolescent girl component of ICDS should be strengthened. Government, NGOs and civil society should make efforts to instil non-sexist norms and values through advocacy and communication strategies and campaigns using electronic, print and folk media and through open discourses on gender equity with involvement of public figures. Focus should be on elimination of discrimination and abuse of girls and on creating awareness of existing legislations. 9) Advocacy and Awareness: The media should be used to spread awareness on child rights. Debates and discussions with participation of children can be a regular feature on electronic media in order to enhance peoples knowledge and sensitivity on child protection issues. While media coverage of child protection issues is desirable, it is essential that the coverage is done in such a way that it prescribes to high ethical standards of reporting such as avoiding disclosure of the identity of the child victim to reduce the childs trauma and prevent re-victimization of the child. It is also essential to obtain informed consent of the child in cases of reporting. All these measures will protect the child from the stigma attached to abuse and prevent sensationalization of the issue. The Ministry of Information and Broadcasting and media self regulatory authorities should take necessary action to develop ethical standards for the media and to implement them. 10) Research and Documentation: The national study has thrown open various avenues of research which need to be undertaken in order to further strengthen some of the findings emanating from the study. These areas for research could include: 1 Child Rights 2 Violence and its impact on children 3 Causes and impact of different forms of child abuse 4 Issues around children in conflict with the law 5 Corporal punishment in schools 6 Urban poverty and children 34
Working children with special reference to child domestic workers and children working in dhabas and tea kiosks etc. among others 8 Neglect of children 9 Gender discrimination 10 Orphans and the adoption system Good practices in protection should be documented and shared to facilitate qualitative improvement at all levels. 11) Child Protection Data Management System: The biggest challenges in child protection are the creation of a database of all child protection services, linking of lateral services, creation of a knowledge base, and tracking of missing children, all of which have to be addressed at the grass-root level. The database, therefore, should be developed at the district level itself with upward and lateral linkages. 12) Child Participation: Childrens voices need to be heard by everyone. All for addressing issues of child rights should have adequate childrens representation with the opportunity for them to express their views. For example, school curricula should be developed with the active participation of children; children should be involved in development of the district child protection plan, children should be involved in management of schools and institutions, etc. It is mandatory that peer education, peer training and peer participation should be part of each and every school mental health program. Prohibition of Child Marriage Act 2006: Under the provision of the act man marrying a girl below the age of 18 years would be punished and the marriage would be declared null and void. The law has provided stringent penal measures for those aiding, abetting child marriages and has given rights to child couple to nullify their marriage in two years of becoming adults. Section 375 of I.P.C. defines the offence of rape, says it is not an offence if a man co-habits with his minor wife, thus virtually legalizing child marriage. However, there are successful models that have been developed to achieve local socio-cultural needs without following standardised guidelines. All India Education Interventions - some examples
Hard to reach children centre (Assam) Residential Bridge Course for Domestic Child Worker (Andhra Pradesh) Boat School for fishermen community (Andhra Pradesh) Learning Centres and Residential Bridge Course for street and working children (Delhi)

Residential Camp for Older Children (Gujarat) Special schools for Migrating Community (Jammu & Kashmir) Flexi schools, tent schools, mobile schools & Sandhya Kalika (Karnataka) Mobile Schools & Shiksha Ghar for Migrating Children (Madhya Pradesh) Human Development Centre for Urban Deprived Children (Madhya Pradesh) Seasonal Schools and Residential Camps for Migrating Children (Maharashtra) Seasonal Hostels for Migrating Children (Orissa) Drop in Centres and Special Residential Camps for older children (Tamil Nadu) Residential Camps and Transportation Facility for slum areas (Rajasthan) Residential Bridge Courses (Uttar Pradesh)
Multigrade Learning Centre for children in forest areas (Kerala). Model Right to Education Bill, 2006 The Constitution (86th Amendment) Act, 2002, enacted in December 2002 seeks to make free and compulsory education a Fundamental Right for all children in the age-group 6-14 years by inserting a new Article 21A in Part III (Fundamental Right) of the Constitution. The new Article 21A reads as follows: 21A. Right to Education: The State shall provide free and compulsory education to all children of the age of six to fourteen years in such manner as the State may, by law, determine. The reconstituted Central Advisory Board of Education (CABE) in its meeting on 10-11 August, 2004, had constituted a Committee under the Chairmanship of Shri Kapil Sibal, the then Minister of State for Science & Technology and Ocean Development, to suggest a draft of the legislation envisaged under Article 21A of the Constitution. The Report of the Committee, containing essential provisions of the draft legislation, was submitted on 2-7-2005, and considered by CABE in its meeting on 14-15th July, 2005. Based on the suggestions and comments received during the CABE meeting, a complete version of the draft legislation was prepared and sent to Chief Secretaries of all States / UTs and placed on the website for comments from the public at large. In the meanwhile, the PM constituted a small group on the Bill to examine its legal,
constitutional and financial implications, comprising HRM, Finance Minister, Dy. Chairman, Planning Commission and Chairman of the PMs Economic Advisory Council. Based on further consultations in the matter, it was proposed that instead of Central Legislation, a Model Right to Education Bill should be formulated and circulated as a framework to States. Accordingly, a Model Bill on Right to Education has been drafted and sent to the states for their comments. Article 46 of the Constitution states that, The State shall promote, with special care, the education and economic interests of the weaker sections of the people, and, in particular of the Scheduled Castes and Scheduled Tribes, and shall protect them from social injustice and all forms of social exploitation. Articles 330, 332, 335, 338 to 342 and the entire Fifth and Sixth Schedules of the Constitution deal with special provisions for implementation of the objectives set forth in Article 46. These provisions need to be fully utilized for the benefit of these weaker sections in our society. The Constitutional (86th Amendment) Bill, notified on 13 December 2002 provides for free and compulsory elementary education as a Fundamental Right, for all children in the age group of 6-14 years. Sarva Shiksha Abhiyan has a principal of zero rejection for all students. The same should apply to all the education and training system of all children. It is true for normal child but more so for special children in need of training and education. Article 45 of the Indian Constitution states that, The State shall strive to provide free and compulsory education to all citizens up to the age of 14. At present, all political parties in Indian have expressed their commitment to convert this Directive Principle into the Fundamental Right to Education. This famous 83 rd Amendment, introduced in 1997, has not yet been enacted, but hopefully will soon be. It needs to be firmly kept in mind as an indication of success possible through the commitment of successive governments to providing elementary education to the children of India. The outcome of this persistent commitment has increased the literacy rate to 61% (Literacy Day September 2007) in the country. Gross Enrolment Rate is 93.2% and the drop out rate is consistently declining (ASER 2003). Currently it is 39% in primary school stage and 66% at secondary school stage (7th All India Educational Survey NCERT 2002). Infrastructure development to provide a child primary education as the constitutional right has not seen expected growth to match the population.

35
Policy/Program National Policy for Children (NPC)
Year 1974 -
Areas Covered Comprehensive Health for all Children
Implementation with Reference to Children
Planning, review and coordination - Centra/State level Childrens Non Formal Education for out of Board school children Education, Treatment, Training & Rehabilitation for socially deprived, Physically and Mentally Challenged children and facilities towards this Focus on the Family to enable children
Integated Child Development Services (ICDS)
Welfare Sector
Early Intervention Physical, Anganwadi for every 10000 Nutrition, Psychological and Social Development population immunization, health check ups, of the Child referral, non formal preschool education Equal Educational Facilities for Orthopaedically Challenged, Mild Sensory Impaired, Mild Developmentally Delayed, Learning Disbaled, Multiple Handicaps. Promotion of integration of the differently abled children into the mainstream school wherever possible. Capacity Building of Special Teachers and Establishment of Resource Rooms/ teachers in regular schools for differently abled children.
Integrated Education for the Disabled Children (IEDC)
36

P. C. Shastri : Child And Law District Rehabiliatation Center Scheme (DRC) of the Identification, assessment, home Sensitization training, vocational training, Self Help Rehabiliatation Workers at the various levels towards the initiatives for those with disabilities psychological aspects of chidlren with mental retardation & disabilities. More as a Program and not a Policy with continuopus implementation. National Health Policy 1983 Stress on Primary Health Care with Improvement of Mother Child emphasis on Preventive, Promotive and Health, Decrease in Infant Mortality. Rehabilitative Aspects Minimal focus on School Health Program Child Mental Health addressed indirectly only. National Policy on Education Equal Educational Opportunities to Uniformity of the throughout the country everybody. Free Education at school level system
Ministry of Welfare
1968
Differentiation of the Preschool, elementary, secondary school education Integrated education for the disabled
National Mental Health Program
1982
Mental Health to form an integral part Recognizes the Need for data on Child Mental Health Problems of Health Services in all states Minimum standard of mental health Multipurpose workers trained to address some of the Child Mental care to available to all Health issues epilepsy, mental Application of mental health in health retardation, behavioural problems in children care and social development. Focus on community participation PHC personnel to actively liaise with schools and anganwadis for identification. Intervention aspects of child mental issues
National Policy on Mental Handicap
1987
Evolve a policy concerning health, Formation of National Trust & education, social security, and National Information Center. legislative measures for improving the quality of life of mentally handicapped Early Identification persons in India. Special Schools and Ensuring availability and accesibility of Rehabiliatation. basic care for all mentally handicapped Self Help Groups persones in future. Promote community participation Pilot programs to be set up towards the above. 37

P. C. Shastri : Child And Law The National Crime Record Bureau offers a chilling piece of statistics; since 1991 the reported cases of Pedophilia (rape of children below 10 years) have show a mind numbing increase of 278 percent. Inspite of legal provision the gender equality is conspicuously missing. The following data raises concerns. Table 2 : The neglect, killing and multiple type and level of abuse of female child. Type of Abuse Abortion after amniocentesis Death in 1st five years Malnutrition Infanticide Education Household work and baby sitting Sexual worker Child Labour-increase with age of the girl child Dowry death Wanting a male child by female Adoption Child Marriage S T D in children below 7 years Male .0199 52/1000 33 0 70 10 10 30 0 32 5 30 10 Female .99 60/1000 67 100 30 90 90 70 100 78 95 70 90 multidimentional exploitation inflicted both at home and work-place; economically, sexually, personally and educationally. This results in poor identity and self-worth of the child. Legislative and social changes through mass movement on community awareness in the direction of compulsory schooling, have failed to ensure the rights of childhood to Indian child. Examining the government policies and national program for promoting child mental health it becomes evident that there is a wide gap between the childrens needs and existing resources. There is neither an independent nor integrated child mental health policy in India. The multiple needs of a child are currently covered by different policies and subsequently different ministries. It is crucial to develop a comprehensive policy to cover all aspects of childrens mental health, under one umbrella. The incidence of children needing mental health services is high. Even after sixty one years of independence, resources to meet the mental health needs of children, human power, as well as preventive, diagnostic and treatment services, are extremely limited. What is the gap due to? Inadequate government policy, unaroused citizenry, insufficient resources or the lackadaisical attitude of people towards the needs of children. Inspite of multiple legal provisions to provide child all the rights and privileges, Indian child continues to struggle and face challenges in the form of deficiencies and deprivations. Single window operation for child health, education and welfare will surely go a long way in successful implementation of various child legislations providing right control, quick results and ensuring justice.
A typical Indian child starts his/her life in the womb with intrauterine growth retardation (30 percent) and continues to have deprivation and discrimination all through his/her life. Indian child undergoes
Correspondence: Prof. P.C.Shastri MD 3/3, Vivina Bldg., S.V. Road, Andheri (W), Bombay - 400 058, INDIA. Phone: +91 22 26282828 Cell: +91 9821349317 e-mail: pcs910@hotmail.com Fax: +91 22 26282828
38

Original Article
Depression in Gynecology OPD

Snehal Goswami G.K.Vankar
Abstract Background: Depressive disorders are most commonly found psychiatric morbidity in women attending gynecology OPD, but in the developing world, there is under recognition of these conditions. Aims: To study frequency and severity of depressive disorders in gynecology OPD and its association with gynecological risk factors and psychosocial stressors. Methods: 507 consecutive patients attending gynecology OPD were screened for depression with Brief PRIMEMD PHQ; severity of depression was assessed by Hamilton Rating Scale for Depression. Demographic characteristics of both the group (depressed and not depressed) were compared and chi-square and t-test were applied for statistical analysis of data. Results: Out of 507 patients, 178 (35.1%) patients had depression (major depression 19.7% and minor depression 15.4%). Gynecological risk factors like premenstrual symptoms, menopause, hysterectomy and tubal ligation were significantly associated with depression. Depression was more common in patients having psychosocial stressors, particularly, physical violence, infertility, alcoholic husband, financial worries, having no one to turn to with a problem, health related stressor, conflicts with spouse, stress about taking care of family member and stress about work outside home. Conclusion: Depression is the common psychiatric condition frequently found in a gynecology OPD and significantly associated with particular gynecological risk factors and psychosocial stressors. Key words: depression, gynecology, outpatients Introduction: Reproductive health, in its broadest definition, has been described as a fundamental and inalienable part of womens health. Mental health is a part of reproductive health; this remains, at best, a peripheral and marginal concern. Association between emotional lives of women and reproductive health has been recognized. Psychiatric morbidity is significantly associated with gynecological problems like abortion, infertility, menstrual abnormality, pelvic pain etc [1] and depressive disorders are most commonly found psychiatric morbidity in women attending gynecology OPD [2], [3] but in the developing world, there is under recognition of these conditions. [4] Major depression is a significant public health problem through out the world and most common psychiatric problem in primary care setting. [5] Women experience major depression twice as often as men. [6] Patient with depressed mood show loss of energy and interest, feeling of guilt, difficulty in concentrating, loss of appetite and thought of death or suicide. These disorders always result in impaired interpersonal, social and occupational functioning. Risk of untreated depression include malnutrition, use of illicit substances, psychotic symptoms, refusal of prenatal care [7] lower APGAR scores, poor perinatal Archives of Indian Psychiatry 8(2) October 2007
outcome and preterm labor. [8] Paucity of Indian studies about depression in gynecology setting made this work to be taken. Aims and Objectives: 1 To find the frequency of depressive disorders in patients attending gynecology OPD. 2 To assess severity of depressive disorders and comorbidities in depressive disorders. 3 To study an association between depression and menstrual or reproductive status. 4 To study an association between depression and recent psychosocial stressors. Material and Methods: The study was conducted at Obstetrics and Gynecology O.P.D. Civil Hospital Ahmedabad. 507 consecutive patients attending the OPD were included in study. All of them were asked about their demographical details, presenting complaints, co-morbid medical conditions, current reproductive status (menstrual phase/ pregnancy/Lactational amenorrhea) and gynecological history (premenstrual symptoms, gynecological operation, h/o still birth, abortion, or MTP). Then they were screened for depression by BRIEF PRIME-MD Patient Health Questioner (Gujarati version). The PRIME-MD [9] was the first mental health 39
S. Goswami, G. K. Vankar : Depression in Gynecology OPD diagnostic test that could be entirely self-administered by the patient. The shortened version of the Prime MD is called the Patient Health Questionnaire. It is a selfadministered questionnaire that is 85% effective in suggesting the presence of a mental health problem The Brief PHQ consists of nine items corresponding to the nine criteria for major depression as per DSM IV [10] (DSM IV American Psychiatric Association, 1994) for the time frame of last two weeks to be rated on a 4-point scale (0= not at all, 1=frequently, 2= more than half of the days, 3=almost daily). Major depression was diagnosed when person rates at least five symptoms as 2 or more with sadness of mood or lack of pleasure as essential criteria. Persons who have these essential criteria present plus 2 or 3 responses rated 2 or 3 were considered as having major depressive disorder. The ninth item related to suicidal ideas was rated as present even if it were present for less than half of the days. Minor depression was diagnosed when person rates less than five symptoms as 2 or more with sadness of mood or lack of pleasure as essential criteria In a study of 3,000 patients who used the Brief PHQ, about 30% had a mental disorder according to the questionnaire. [9] It took the doctors about 3 minutes on average to review the questionnaire and most of the doctors agreed with the PHQ result This instrument is extensively used in India and has been translated in all major languages. Depressed patients were further assessed for severity of depression by Hamilton Rating Scale for Depression (Hamilton, 1960) [11] It has 24 item scored from 0 to 2 or 0 to 4 with total score ranging from 0 to 50. Score of 7 or less may be considerer normal; 8-13 mild; 14-18 moderate; 19-22 severe; and 23 and above, very severe. Depressed patients were explained about their illness and availability of psychiatric treatment. Then they were asked about their own opinion for need to consult psychiatrist. Patients who were concerned for treatment were prescribed anti-depressant accordingly and advised for follow-up in psychiatry OPD. Data Analysis: Depressed and non-depressed groups were compared for demographic characteristics, psychosocial stressors and gynecological risk factors. Chi-square and ttest applied appropriately Analysis of data was done using SPSS Xth version 2002. p value<0.05 was considered significant. RESULTS Demographic characteristics: Age of the patients ranged from 13-70 years with a mean age of 27 year. Around 1/3rd of them (147, 29%) were illiterate, only 3% (15) had studied up to graduation and rest had 40
education up to primary or high school level. Vast majorities (393, 77.5%) were housewives and had no employment out side home and only some (114, 22.5%) had employment outside home. Most of them (436, 86%) had monthly income of Rupees 4000 or less and only a few of them (71, 14%) had income more then Rupees 4000; 312(61.5%) belonged to joint families and the rest were coming from nuclear families. Almost all (488, 96.2%) were married and very few (19, 3.7%) were single (unmarried, divorced, separated, widowed). 452(89.1%) had urban background while 55(10.8%) were from rural areas. PHQ Distribution: All 507 consecutive patients were screened by Brief PRIME-MD PHQ, PHQ score ranged from 0-24, mean 4.88, median 3.Figure 1 shows PHQ score distribution of 507 patients. Prevalence of depression Of the 507 consecutive patients screened, 178(35.1%) were having depression. Among them 100(19.7%) were suffering from major depression and other 78(15.4%) had minor depression. Depression in Obstetrics: Of the pregnant 257 subjects, 52 (20.2 %) had depressive disorder; among them 25 (9.7%) had major depression and 27 (10.5) had minor depression. No significant difference was found between trimesters of pregnancy and depression. Depression in Gynecology: Out of 250 gynecological patients, 126 (50.4%) had depressive disorder; among them 75 (30%) had major depression and 51 (20.4%) had minor depression. Depression was more common in women having gynecological problems compared to women having pregnancy and related problems(p<0.001).
200 180 174 160 140 120 100 80 60
41
40
24 24 25 20 9
20 0
0 1 2 3 4 5
15 13
20 12
18 19 10
17 15 9 5 6
13 3
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Score

S. Goswami, G. K. Vankar : Depression in Gynecology OPD Table 1: Socio-demographic characteristics and Depression
Characteristics Depression present N=178 n(%) 16-70 30.2( 9.5) 56 (31.5) 80 (44.9) 42 (21.3) 131 (67.9) 47 (26.4) Depression absent N=329 n(%) 13-50 25.2(5.46) 91 (27.7) 111 (33.7) 127(25.04) 262 (79.6) 67 (20.4) Total (%) P value
Age in years
Range Mean(SD) Illiterate Primary High school and higher education Housewife, no employment Employment outside home <2000 2000-2999 3000-3999 >4000 Joint Nuclear Married Unmarried, Divorced, Separated, Widow 0 1 2 3 ?4 0 ?1 0 1 2 ?3 Rural Urban
13-70 27(7.54) 147(28.9) 191(37.7) 169(33.33) 393(77.5) 114(22.5)
P<0.0001
Education
P=0.002
Occupation
P=0.11
Income
78 (43.8) 54 (30.3) 25 (14) 21 (11.8) 93 (52.2) 85 (47.7) 166 (93.2) 12 (6.7) 51 (28.6) 38 (21.3) 34 (19.1) 28 (15.7) 27 (15.2) 75 (42.1) 103 (57.9) 81 (45.5) 39 (21.9) 38 (21.3) 20 (11.2) 25 (14) 153 (85.9)
120 (36.5) 95 (28.9) 64 (19.4) 50 (15.2) 219 (66.5) 110 (33.4) 322 (97.9) 7 (2.1) 146 (44.4) 88 (26.7) 68 (20.7) 19 (57.7) 8 (2.4) 208 (63.2) 121 (36.8) 157 (47.7) 95 (28.9) 64 (19.4) 13 (3.9) 30 (9.1) 299 (90.9)
198(39) 149(29.4) 89(17.5) 71(14) 312(61.5) 195(38.5) 488(96.2) 19(3.7) 197(38.9) 126(24.8) 102(20.1) 47(9.3) 35(6.9) 283(55.8) 224(44.2) 238(46.9) 134(26.4) 102(20.1) 33(6.5) 55(10.8 452(89.1)
P=0.2
Family Marital status
P=0.001 P=0.009
No of children
P<0.001
No of male child No of children<12
P<0.001 P=0.007
Residence
P=0.88
Severity of depression was measured by Hamilton Depression Severity scale. Almost half of patients with major depression 86(48%) had mild depression, 41(23%) had moderate depression, 24(13.5%) had severe and 27(15.2%) had very severe depression. Suicidal ideation: Out of all patients screened, 53 (10.45%) patients reported suicidal ideas; all of them were suffering from depression.
Socio-demographic characteristics and depression: Depression was more common in women aged more than 30 years (p<0.0001) Higher education (=high School) was protective factor for depression. (p=0.002) Patients coming from nuclear family were more prone for depression compare to joint one (p=0.001) Depression was more common in unmarried, separated, divorced and widow women in compared to married women ( p=0.009). Depression was more common in women having 4 or more children (p<0.001) and beside these, there were no differences in demographic characteristics. 41

S. Goswami, G. K. Vankar : Depression in Gynecology OPD Table 2: Depression and gynecological risk factors:
Gynecological risk factors Reproductive status Depression present N=178 n (%) 26 (14.6) 4 (2.2) 21 (11.8) 25 (14) 21 (11.8) 25 (14) 2 (1.1) 52 (29.2) 2 (1.1) 50 (28.1) 58 (32.6) 4 (2.2) 3 (1.7) 10 (5.6) 12 (6.7) 34 (19.1) 17 (9.5) Depression absent N=329 n (%) 21 (6.4) 10 (3) 22 (6.7) 23 (6.9) 4 (1.2) 40 (12.2) 0 205 (62.3) 4 (1.2) 43 (13.1) 52 (15.8) 4 (1.2) 2 (0.6) 3 (0.9) 29 (8.8) 21 (6.4) 12 (3.6) Total (%) P value
Menstruating
Menstrual phase Regenerative Phase Proliferative Phase Secretory Phase Amenorrhea Lactational amenorrhea Pregnancy Not known Premenstrual symptoms** Irregular menses*** Child birth within 6 months Miscarriage within 6 months Hysterectomy Cesserian section Tubal ligation
47(9.27) 14(2.76) 43(8.48) 48(9.46) 25(4.93) 65(12.82) 2(0.39) 257(50.69) 6(1.18) 93(18.34) 110(21.69) 8(1.57) 5(0.98) 13(2.56) 41(8.08) 55(10.84) 29(5.71)
0.36
Menopause Amenorrhea
0.004 0.54 0.23 0.00 0.73 0.01 <0.001 0.6 0.4 0.003 0.4 0.00001 0.006
Menstrual Problems Recent Changes H/o operation
H/O distress due to adverse pregnancy outcome
Depression was more common in unmarried, separated, divorced and widow women in compared to married women ( p=0.009). Depression was more common in women having 4 or more children (p<0.001) and beside these, there were no differences in demographic characteristics. Depression and gynecological risk factors: Depression was more common in menopausal women (p=0.004); women having premenstrual symptoms (p<0.001); irregular menses (p<0.001) women having past history of hysterectomy (p=0.003);women having past history of tubal ligation (p=0.00001),and past h/o distress due to adverse pregnancy outcome.(p=0.006) No association was found between phase of menstrual cycle and depression. Similarly, childbirth / miscarriage within 6 months and h/o cesarean section were not significantly associated with depression. Depression and psychosocial stressors Table presents the frequencies of the psychosocial stressors included in PHQ, as well as the association of 42
each stressor with depression. The most common stressors were health related (31.9%), about taking care of family members (25.6%), financial worries (24.6%) and conflict with spouse (16.1%). Depression was significantly associated with health related stressor (p<0.001), stress about low sexual desire and pleasure (p<0.001), conflicts with spouse (p<0.001), stress about taking care of family member (p<0.001), stress about work outside home (p=0.0001), financial worries (p<0.001) and having no one to turn to with a problem (p<0.001). Very few patients reported stress about weightand look (0.7%), something bad happened and look (0.7%),something bad happened recently (1.9%) and thinking/dreaming about terrible past (0.9%) and these stressors were not significantly associated with depression. Depression and the most stressful thing in life: In response to the question about most stressful thing in life right now, patients reported various things mentioned in table 8.Among them infertility (3.1%) and physical violence (2.5%) were more common. Alcoholic husband (p=0.003), childrens future (p<0.001), Archives of Indian Psychiatry 8(2) October 2007
D:\Dr. / 42
G.K.
Vankar
S. Goswami, G. K. Vankar : Depression in Gynecology OPD Table 3: Depression and psychosocial stressors:
Psychosocial stressor Severity Depression present N=178 N (%) 73(41) 33(18.5) 72(40.4) 176(98.9) 1(0.6) 1(0.6) 169(94.9) 4(2.3) 5(2.8) 112(62.9) 9(5) 57(32) 80(44.9) 25(14) 74(41.6) 161(90.4) 6(3.4) 11(6.2) 88(49.4) 28(15.7) 62(34.8) 148(83.1) 10(5.6) 20(11.2) 170(95.5) 0 8(4.5) 176(98.9) 1(0.5) 1(0.5) Depression absent N=329 N (%) 272(82.7) 29(8.8) 28(8.5) 327(99.4) 1(0.3) 1(0.3) 323(98.2) 6(1.8) 0 313(95.1) 9(2.7) 7(2.1) 297(90.2) 19(5.8) 12(3.6) 319(96.9) 9(2.7) 1(0.3) 294(89.4) 17(5.2) 18(5.5) 326(99.1) 1(0.3) 2(0.6) 327(99.4) 0 2(0.6) 326(99.4) 1(0.3) 2(0.6) Total (%) P value
Health related*
0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2
345(68.04) 62(12.22) 100(19.72) 503(99.21) 2(0.39) 2(0.39) 492(97.04) 10(1.97) 5(0.98) 425(83.83) 18(3.55) 64(12.62) 373(73.57) 44(8.67) 86(16.96) 480(94.67) 15(2.95) 12(2.36) 382(75.34) 45(8.87) 80(15.77) 474(93.49) 11(2.16) 22(4.33) 497(98.02) 0(00.00) 10(1.97) 502(99.01) 2(0.39) 3(0.59)
0.00
About weight and look
0.9
About Sexual desire and pleasure** Conflicts with spouse***
<0.001
<0.001
About taking care of family member About work outside home
<0.001
0.0001
Financial worries
<0.001
No one to turn to with a problem Something bad happened recently Thinking/dreaming about terrible past
<0.001
7.13
0.06
Severity of stressor: 0= not bothered, 1= bothered a little, 2= bothered a lot husbands unemployment (p=0.018), infertility (p=0.004) and physical violence (p<0.001) were significantly associated with depression. For other stressful things reported by patients no significant association had been found. Correlation between number of stressors and severity of depression Increase in number of stressors significantly correlated with more severe depression, which is manifested by higher Hamilton score(r=0.881, p<0.001) Opinion about need to consult psychiatrist Of the 178 patients having depression only 50 (28.1%), were concerned about need to consult Archives of Indian Psychiatry 8(2) October 2007
psychiatrist for their problem, other 128 (71.8%) were not concerned at all and Only 9 (5%) were taking treatment for depression at that the time of interview. DISCUSSION Frequency of depression in Obs-Gynecology OPD: Earlier studies done in gynecology department found high rates of depression, ranged from 13% [3] to 70% [12] A case-control study done by Agarwal et al (1990) also revealed that women attending a gynecological clinic for physical health problem were found to have a marked psychological disorder as compared to the control group.
[13]
43
S. Goswami, G. K. Vankar : Depression in Gynecology OPD Table 4: Depression and most stressful thing in life
Depression present N=178 N (%) 12(6.7) 11(6.2) 9(5.1) 7(3.9) 7(3.9) 6(3.4) 3(1.7) 3(1.7) 1(0.5) 1(0.6) 1(0.6) 1(0.6) 1(0.6) Depression absent N=329 1(0.3) 5(1.5) 0 2(0.6) 1 (0.3) 0 0 0 0 0 0 0 0 Total (%) p value
Most Stressful life event Physical violence Infertility Childrens future Husbands unemployment No son Alcoholic husband Bedridden husband No live issue Son left home Daughters marriage Disobedient son Fetal malpresentation Loss of parent
13(2.56) 16(3.15) 9(1.77) 9(1.77) 8(1.57) 6(1.18) 3(0.59) 3(0.59) 1(0.19) 1(0.19) 1(0.19) 1(0.19) 1(0.19)
<0.001 0.004 <0.001 0.018 0.005 0.003 0.07 0.07 0.75 0.75 0.75 0.75 0.75
In this study, 35.1% of patients attending ObsGynecology OPD had depression (major depression, 19.7% and minor depression15.4 %-); this rate is comparable to earlier finding of Hsiao et al., i.e. 36% [2] Depression is less common in women having pregnancy and related problems in compare to women having gynecological problems; similar to earlier findings.
[3, 14, 15]
findings
[20]
In our study no significant association had been found between residence and depression similar to earlier studies. [2, 3] Most of previous studies found only a weak but consistent correlation between depressive disorders and lower socioeconomic status. Although, the association of depression with poverty-related variables, such as hunger and low level of education had been found [21, 22] in our study no significant association was found between income and depression. In this study, no significant difference were found among employment status of women and depression similar to earlier study.[2] but, husbands unemployment was significantly associated with depression in women. Earlier study, [2] found that depression was less common in patient with higher education. but no significant association has been found. Here in our study higher education was protective factor for depression. Patient coming from nuclear family were more prone for depression. This can be explained by lake of social support. Male child preference and depression: Kamel et al [23] reported that women who desired male child scored significantly higher depressive symptoms than those who desired female child. Depression may occur in women who are not carrying their preferred-sex fetus.
No significant difference was found among trimesters of pregnancy and depression. Demographic characteristics: Although, earlier studies found no significant difference in age groups; [2] [3] in our study depression was more common in women aged more than 30 years which is congruent to general finding that Mean age of onset of MDD is about 40 years with 50% of all patients having an onset between the ages of 20 and 50. Previous studies have found discrepant results concerning the relationship between psychiatric impairment and marital status. [16, 17, 18] These differences may be explained by the use of a variety of research methods. Romans-Clarkson et al. [19] found that married and widowed women showed lower rates of mental illness than women who had never married or who were childless. In our study, depression was more common in unmarried, separated, divorced and widow women in compared to married women which is congruent to earlier 44

S. Goswami, G. K. Vankar : Depression in Gynecology OPD In our study though nearly all women who were not having male child were not having significant association with depression, but women who perceived this as most stressful thing in life were having significant association with depression. We found that depression was more common in women having 4 or more children, which can be explained by more work load, responsibilities and limited resources. Depression and gynecological risk factors In this study, no association was found between menstrual status and depression similar to earlier study. [12] But irregular menses were significantly associated with depression .Only modest relationship between menstrual status and prevalence of mental disorder was noted in one study. [3] Due to controversy about diagnosis of pre menstrual dysphonic disorder and cross sectional study design premenstrual dysphonic disorder has not been diagnosed. But in our study patients were asked about h/ o premenstrual symptoms. i.e. Mood swigs, irritability, sad mood, gabharaman ,Brest pain, and abdominal pain.; that occur just one week before menses and subside after menses. Depression was more common in women having premenstrual symptoms, congruent with finding of Chandra and Yogananda. [4] A higher rate of depression was found in women at menopause, same as previous studies. [24, 25] Although higher rates of mental disorders had been reported in women who are post partum [26] or who have had a recent miscarriage [27], in our study childbirth or miscarriage within 6 months, were not significantly associated with depression similar to findings of Spitzer et al 2000. [3] Our negative findings may have been because the PRIME-MD PHQ focuses only on current disorders and may therefore miss disorders present in the previous 6 months that have already resolved. In our study, higher rates of depression were found in women having past history of hysterectomy, incongruent with earlier findings of Alexander et al. [28] In this study, past history of tubal ligation was significantly associated with depression similar to earlier findings. [29, 30] Depression and psychosocial stressors Depression was significantly associated with health related stressor, stress about low sexual desire and pleasure, conflicts with spouse, stress about taking care of family member, stress about work outside home, financial worries, and having no one to turn to with a problem same as the study done by Spitzer et al.[3] but, in Archives of Indian Psychiatry 8(2) October 2007
our study very few patients reported stress about weight and look(0.7%), Something bad happened recently (1.9%) and thinking/dreaming about terrible past (0.9%) and these stressors were not significantly associated with depression in contrast to Spitzer et al.[3] The infertile women had significantly higher depression scores similar to previous findings. [3] Several authors have reported association between history of abuse and depression. [22, 31, 32] One study done among inner-city, African American women also reveled that depressive symptoms are highest among those reporting both high intimate partner violence levels and alcoholic problems. [33] Study done by Tempier R et al (2006) found higher levels of psychological distress in female spouses of male lifetime at-risk drinkers. [34] In agreement to this we also found significant association between history of abuse, alcoholism of husband and depression. Worry about childrens future was significantly associated with depression; probably because Indian parents are more concerned for childrens future as they consider their children being more dependent on them compared to their western counterparts. Increase in number of stressors is significantly correlated with increase in severity of depression. Because our study design was cross-sectional, it cannot be concluded that the stressors are the cause or the effect of depression. Depression and co-morbid physical condition No significant association found between co-morbid medical condition and depression as reported by Patel et al (2006) [35] Suicide and women: Of the 507 women studied, 50(10.4%) reported suicidal ideas, which is closed to estimated life time prevalence of suicidal ideations (13.5%). [36] Furthermore, all the women who reported suicidal ideas were suffering from depression. By screening them for depression and suicidal ideation, early interventions can possibly prevent suicide. In a study of suicide in Tamil Nadu, average annual suicide rate for women was 53 per 100000.Three fourth of all suicide were in socially and economically productive group of 15-44 years of age. Particularly at the age of 1524 year, female suicide rate (109/100000) exceeded male suicide rate (78/100000). Suicide accounted for around 49% of death in women of this age. [37] Here, our study represents a group of 507 women, whose age ranged from 13 to 70 years; with mean age 27 years. The present study demonstrated the need for 45
S. Goswami, G. K. Vankar : Depression in Gynecology OPD mental health services in a gynecologic setting. A high proportion of women (95%) who visited gynecology OPD had never previously visited any mental health service. Even, from the 178 patients having depression, only about 1/4th (28.1%) were concerned about need to consult psychiatrist for their problem. These results suggest that, in a society in which there is a stigma associated with mental illness, women with mental health problems still hesitate to visit a psychiatric clinic. Strengthening the ability of primary care physicians and gynecologists to detect and treat mental illness is the best policy. The availability of a special mental health clinic located in gynecology department may be another choice. By early detection and management of depression, overall reproductive health of women would improve and deaths due to suicide can be prevented. Limitations: Most of the patients studied came from low socioeconomic class as the study center is a public hospital providing free clinical services, they do not represent all women. As the study design was cross-sectional, it can not be concluded whether stressors were the cause or effect of depression. Summary and Conclusions: [6] Nigeria. Journal of Psychosomatic Research1992; 36(5):485-90 [2] Hsiao M-C, Liu C-Y, Chen K-C Characteristics of women using a mental health clinic in gynecologic out-patient setting. Psychiatry and Clinical Neurosciences 2002; 56:459-63. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetricgynecologic patients: The PRIME-MD Patient Health Questionnaire ObstetricsGynecology Study. American Journal of Obstetrics and Gynecology 2000; 183: 759769. Chandra PS, Yogananda BH. Psychiatric aspects of reproductive health in women. Handbook of Psychiatry, A South Asian Perspective 2005; 373-91. Dubovsky SL, Buzan R. Mood disorders. In: Hales RE, Yudofsky SC, Talbott JA, Eds. The American Psychiatric Press textbook of psychiatry. 3rd ed. Washington, DC: American Psychiatric Press 1999; 479-565 Weissman MM, Bland RC, Canino GJ, Greenwald S, Faravelliet C. et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA 1996; 276(4):293-9. . Young SA, Campbell N, Harper A. Depression in women of reproductive age. Post graduate Medicine 2002; 112(3):45-50 Cohen LS. Update on reproductive safety of psychotropic medications. Cur Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study.JAMA 2000; 282:1737-44. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association. (1994).
[3]
[4]
[5]
Of the 507 consecutive patients screened at

gynecology OPD 35.1% of patients had depression (major depressio19.7% n, and minor depression, 15.4 %).
[7]
[8] [9]
Depression was more common in women older than 30 years; unmarried, divorce, separated or widow women; and in women having 4 or more children. Gynecological risk factors like premenstrual symptoms, menopause, hysterectomy and tubal ligation were significantly associated with depression. Depression was more common in patients having psychosocial stressors, particularly, physical violence, infertility, alcoholic husband, financial worries, having no one to turn to with a problem, health related stressor, conflicts with spouse, stress about taking care of family member and stress about work outside home. 10.4% patients reported suicidal ideas; all of them were also suffering from depression.
[10]
[11] Hamilton MA .Psychiatric Rating Scales. In: Sadock BJ, Sadock VA, editors. Comprehensive Textbook of Psychiatry; 8th edition: Lippincott Williams & Wilkins; 2005.pp944-45. [12] Chaturvedi SK, Chandra PS, Prema SV , Issak MK , Sudarshan CY et al. Detection of psychiatric morbidity in gynecology patients by two brief screening methods. Journal Psychosomatic Obstetrics and Gynecology 1994; 15:53-8. Agarwal P, Malik S, Padubidri V. A study of psychiatric morbidity in a gynecology outpatient
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S. Goswami, G. K. Vankar : Depression in Gynecology OPD clinic. Indian Journal of Psychiatry 1990; 32:57-63. [14] Kelly R, Zatzick D, AndersT. The detection and treatment of psychiatric disorders and substance abuse among pregnant women cared for in obstetrics. American Journal of Psychiatry 2001; 158:213219 Robbins J, Kirmayer L, Cathebras P, Yaffe MJ , Dworkind M. Physician characteristics and the recognition of depression and anxiety in primary care. Medical Care 1994; 32:795812 Birchnell J. Psychiatric disorders in marriage. British Journal of Hospital Medicine 1986; 35: 409412. Cochrane R, Stopes-Roe M.Women, marriage, employment and mental health. British Journal of Psychiatry 1981; 139: 373381. Segraves RT Marriage and mental health. Journal of sex and Marital Therapy 1980; 6 Romans-Clarkson SE, Walton VA, Herbison GP, Mullen PE. Marriage, motherhood, and psychiatric morbidity in New Zealand. Psychological Medicine 1988; 18: 983990. Rihmer Z, Angst J .Mood disorders: Epidemiology. In: Sadock BJ, Sadock VA, editors. Comprehensive Textbook of Psychiatry; 8 th edition: Lippincott Williams & Wilkins; 2005.pp1579-80. [21] Patel V, Araya R, de Lima M , Ludermir A, Todd C. Women, poverty and common mental disorders in four restructuring societies.Soc, Sci Med. 1999; 49(11):1461-71 Patel V, Desouza N, Rodrigues M. Gender, poverty, and postnatal depression: a study of mothers in Goa, India. American Journal of Psychiatry 2002; 159 (1):43-7 Kamel HS, Ahmed HN, Eissa MA, Abol-Oyoun al-S M. Psychological and obstetrical responses of mothers following antenatal fetal sex identification. J Obstet Gynaecol Res.1999; 25(1):43-50. Hunter M, Battersby R, Whitehead M Relationship between psychological symptoms, somatic complaints and menopausal status. Maturitas 1986; 8:217-88. Sagsoz N, Oguzturk O, Bavram M , Kamaci M Anxiety and depression before and after the menopause. Archives of Gynecology and Obstetrics 2001; 264(4):199-202. Yonkers KA, Chantillis SJ. Recognition of depression in obstetrics/gynecology practices. [36] [29] [27] American Journal of Obstetrics and Gynecology 1995; 173(2): 632-8 Thapar AK, Thapar A. Psychological sequelae of miscarriage: a controlled study using the General Health Questionnaire, and the Hospital Anxiety and Depression Scale. British Journal of General Practice 1992; 42:94-6. Alexander DA, Naji AA, Pinion SB, Mollison J, Kicthner HC, Parkin DE, Abramovich DR, Russell IT. Randomized trial comparing hysterectomy with endometrial ablation for dysfunctional uterian bleeding: psychiatric and psychosocial aspects. British Medical Journal 1996; 312(7026): 280-4 Wig NN, Gupta AN, Khatri R , Varma SK A prospective study of psychiatric and menstrual disturbances following tubal ligation. The Indian Journal of Medical Research 1977; 66:581-90. Bhatia JC, Cleland J. Self-reported symptoms of gynecological morbidity and their treatment in South India. Studies in Family Planning 1995; 26:203-16. Poleshuck EL, Giles DE, Tu X. Pain and depressive symptoms among financially disadvantaged womens health patients. Journal of womens Health 2006; 15(2):182-93. Verma D, Chandra P, Thomas T Intimate partner violence and sexual coercion among pregnant women in India: Relationship with depression and post-traumatic stress disorder. Journal of Affective Disorders 2006.14 [Epub ahead of print] Paranjape A, Heron S, Thompson M , Bethea K, Wallace T, et al. Are alcohol problems linked with an increase in depressive symptoms in abused, inner-city African American women? Womens Health Issues 2007; 17(1):37-43. Tempier R, Boyer R, Lambert J, Mosier K, Duncan CR et al. Psychological distress among female spouses of male at-risk drinkers. Alcohols 2006; 40 (1):41-9. Patel V, Kirkwood BR, Pednekar S, Perira B, Barros P et al. Gender disadvantage and reproductive health risk factors for common mental disorders in women: a community survey in India. Archive of General Psychiatry 2006; 63(4): 404-13. Kessler RC,McGonagle KA,Zhao S, Nelson GB, Hughes M, EshleanS et al. lifetime prevalence and 12-month prevalence of DSM-III R psychiatric disorder in united states, Results from the National Co morbidity Survey. Arch Gen Psychiatry.1994; 51:8-19.
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S. Goswami, G. K. Vankar : Depression in Gynecology OPD [37] Gajalakshmi V and Peto R. Suicidal rates in rural Tamil Nadu, South India: Verbal autopsy of 39,000 deaths in 1997-98.Int.J Epidemiol 2007.
Sources of support : None Conflict of Interest: None Snehal Goswami, MD, Senior Resident G.K.Vankar MD Professor and Head* Dept. of Psychiatry, B.J.Medical College Ward E1, Civil Hospital Ahmedabad 380016 e-mail : drgkvankar@yahoo.com Cell : 9904160338 *Correspondence
48

Original Article
Wechsler Intelligence Scale for Children, IVth edition (WISC IV) A multi-center study
A. Sovani K. Joshi A. Satyanarayana S. Thatte H. Shroff S. Ravi R. Korde S. Savant P. Saraff
Abstract Over 221 normal subjects from the city yielded test scores approximating the distribution of scores reported in the test manual of the WISC IV (Wechsler, 2003). Data from male and female respondents is also reported. Further, inter-correlations between subtests are documented. The test appears to be a very useful tool not only for IQ assessment, but also to assess specific strengths and weaknesses in a number of sub-areas of ability, which would prove useful for LD assessment (Sovani, 2002). This fourth and latest edition of the Wechsler Intelligence scale for Children (WISC IV) is widely used in a number of countries all over the world (Wechsler, 2003). This paper reports the exploratory study conducted through a multi-center initiative in the city of Mumbai, to assess the utility of the WISC IV in a metropolitan setting like Mumbai, using the original test material administered in English. The results reported show that the test can be used very easily in a city population like Mumbai without any difficulty. The distribution of scores fits the normal curve (Sovani et al, 2008), dispelling any anxieties about whether to utilize the test in our setting. Key Words : India, Wechsler Intelligence Scale for Children, IVth edition, Intelligence Test Introduction Several general characteristics of the WISC in general, and the WISCIV in particular, make it a very desirable test to use. It is an individually administered clinical instrument for assessing the cognitive ability of children aged 6 years through 16 years 11 months. The WISC IV has four composite scores (instead of the two that were available with the earlier versions of the test). The total score is labeled the Full Scale IQ (FSIQ). The four composite scores are the 1. Verbal Comprehension Index (VCI) with 5 subtests 2. Perceptual Reasoning Index (PRI) with 4 subtests 3. Working Memory Index (WMI) with 3 subtests and 4. Processing Speed Index (PSI) with 3 subtests. The Verbal Comprehension Index (VCI) requires verbal conceptualization, stored knowledge access and oral expression. The items are orally presented questions that assess common-sense reasoning, reasoning out or retrieving word associations, and the ability to describe the nature or meaning of words. The index reflects knowledge acquired from ones environment, and is one of the best predictors of overall intelligence. The subtests included herein are Similarities, Vocabulary and Comprehension, in addition to Information and Word reasoning which are optional. The Perceptual Reasoning Index (PRI) requires Archives of Indian Psychiatry 8(2) October 2007
visual perception, organization and reasoning with visually presented, nonverbal material to solve the kinds of problems that are largely not school taught. The various subtests herein are block design, picture concepts and matrix reasoning which are new additions, and also picture completion which is optional. Block design requires spatial processing, visual-motor coordination and the ability to apply all skills in a quick, efficient manner. Picture Concepts score may reflect the effect of language on performance. The Working Memory Index (WMI) is a new entity in this version of the WISC, although clinicians did look at freedom from distractibility as a factor earlier as well. This index requires working memory processes applied to the manipulation of orally presented verbal sequences. What is measured is the respondents ability to temporarily retain information in memory, by performing some operation or manipulation with it, and produce a result. This involves attention, concentration, mental control, and some reasoning. The subtests subsumed in this index are digit span as well as a new subtest, letter number sequencing, and the now optional arithmetic subtest. The Processing Speed Index (PSI) which comprises of three subtests, coding, symbol search and an optional cancellation subtest, requires visual perception and organization, visual scanning, and the efficient production
49
Anuradha Sovani et al : Wechsler Intelligence Scale for Children, IVth edition of multiple motor responses. These tasks require executive control of attention and sustained effort while working with simple visual material as quickly as possible. Hence, the WISC-IV has a total of 15 subtests, 10 of which are retained from the earlier edition, and five new subtests: 1. Word Reasoning 2. Matrix Reasoning 3. Letter-Number Sequencing 4. Symbol Search and 5. Cancellation The Wechsler Intelligence Scale for Children, at the point of use of all its editions, is a very widely used instrument for assessing cognitive performance of children, specifically used in most clinical settings for IQ assessment. There have been a number of versions of the WISC available, and the city of Mumbai, where this study was conducted, has seen all of them used in different contexts. Earlier comparative work done between the various available versions (Sovani and Bodas, 2001) highlighted the need to graduate to a more recent version of the test, and also to have a consensus about the version to use. It is always desirable to upgrade testing regimens to the latest edition of any tool, provided adequate norms are available for that tool for the region and language in which testing takes place. A lot of research has been done worldwide on the WISC IV. Findings show that there may be an approximately five point discrepancy to the lower side, because of novelty and its increased difficulty of this newer version of the WISC. The WISC IV has been normed in several countries and on groups without any clinical problem, as well as for special education populations. In the present study, the WISC IV was used without any changes, except for those described in the methodology section below. Data based on a pooled multi-center study is reported and discussed. subjected to a number of statistical procedures to examine relationships between subtests, as well as central tendency measures. This paper focuses more on highlighting gender differences in subscale scores if any, and reporting correlational findings between various index scores. Sample: A total of 211 children were tested, of which 118 were male and 93 were female. Gender wise comparisons of the data have been reported here. The data was collected at three major centers, which are listed in author credits for this paper. All three, viz. Disha, Institute for Psychological Health and Ummeed (in alphabetical order) are non government mental health service facilities in the city of Mumbai, serving a large child and adolescent as well as parent population and also offering a variety of other specialized services. Procedure: Data was collected by testing volunteers at these centers, after taking prior informed consent from parents and assent from the children. The only change made in asking the test questions was with regard to denominations in Arithmetic questions, using Indian currency (rupees) rather than the original currency. No fees were charged for the assessments and rather than a formal report, a brief explanation of the findings on the WISC IV was given to the parents, with a proviso that this study will actually help establish whether this test can be used more routinely. The data was then entered into a common data pool and analyzed. Data analysis: The raw scores arrived at after testing each child were converted to scaled scores using the WISC IV manual and the scaled scores were computed. Findings are reported in this paper include gender wise differences in means, overall subtest means and standard deviations. Previous work reported establishes that normal distributions are indeed arrived at even if international norms are used with the Mumbai sample. (Sovani et al. 2008, in press.) Further, correlations are computed between the various indices.
Methodology:
This study was a multi-center study conducted in the city of Mumbai, and was conducted in order to establish whether use of the WISC IV in the original, would yield a similar profile with Mumbai children as it does with the original normative sample. The application of the study was that, if a major deviation from normality was found, in spite of using normal volunteers for this study, there would be a felt need to conduct a full fledged normative study here in Mumbai. However, if the findings on a normal sample did not deviate markedly from the normative scores from the original manual, perhaps the test may be used as it is, at least in the metropolis of Mumbai. The data obtained was 50
Results:
The age range of children tested in this study was 6 years 1 month, to 16 years 10 months with a standard deviation of 2.62. Means for all the four indices on the WISC IV described above showed mean scores ranged from 96 to 109, with the FSIQ being 100.74. Table I below shows gender wise differences, as well as overall scores obtained from the Mumbai sample of N=221, on the various subtests of the WISC IV. The findings not only reflect the fact that very close approximations to the normative sample were obtained, a fact highlighted in previous work by the same authors (Sovani et al, 2008, in press) but also showing that no major gender differences exist in the data obtained. Gender differences are truly negligible, with the Archives of Indian Psychiatry 8(2) October 2007
Anuradha Sovani et al : Wechsler Intelligence Scale for Children, IVth edition Table-1: Means and Standard deviations (in parentheses) for male and female respondents on the subtests of the WISC IV.
Subtest Block Design Similarities Digit Span Picture Concepts Coding Vocabulary L N Sequencing Matrix Reasoning Comprehension Symbol Search Picture Completion Cancellation Information Arithmetic Word Reasoning Male 9.17 (2.66) 10.48 (3.05) 12.21 (2.96) 9.08 (2.94) 9.65 (3.07) 8.94 (2.81) 11.36 (2.36) 10.48 (2.98) 9.03 (2.94) 9.84 (2.92) 8.65 (2.64) 7.78 (2.84) 11.60 (2.89) 11.28 (2.91) 9.62 (2.77) Female 9.11 (3.10) 10.55 (3.53) 12.17 (3.76) 10.15 (3.20) 10.61 (3.18) 8.84 (3.75) 11.58 (2.49) 10.75 (3.49) 8.93 (3.53) 10.13 (3.02) 8.86 (2.88) 8.17 (3.04) 11.12 (3.28) 10.66 (2.98) 9.43 (3.15) Total 9.15 (2.86) 10.51 (3.26) 12.19 (3.33) 9.96 (3.06) 10.08 (3.15) 8.89 (3.25) 11.46 (2.41) 10.60 (3.21) 8.99 (3.21) 9.97 (2.96) 8.74 (2.75) 7.96 (2.93) 11.39 (3.08) 11.00 (2.95) 9.54 (2.93)
Table 2 : Four indices of the WISC IV and Full Scale IQ gender

Index VCI PRI WMI PSI FSIQ Male 96.40 (14.93) 98.47 (14.14) 109.47 (13.98) 96.62 (14.27) WMI 99.80 (13.54) Female 96.53 (19.13) 99.89 (16.35) 110.12 (15.62) 101.59 (15.15) PSI 101.94 (17.66) Total 96.47 (16.87) 99.09 (15.13) 109.76 (14.69) 98.81 (14.84) 100.74 (15.49)
PRI
FSIQ
VCI PRI WMI PSI
.696(**) .508(**) .364(**) .881(**) Table 3 : Intercorrelations between WISC IV index scores in.859(**) the Mumbai sample .486(**) .395(**) .300(**) .698(**) .607(**)
usual slight male edge in performance tasks and slight female edge in verbal ones. With regard to the intercorrelations, seen in Table III, it is clear that the two traditional Table I below shows gender wise differences, as well as overall scores obtained from the Mumbai sample of N=221, on the various subtests of the WISC IV. The findings not only reflect the fact that very close approximations to the normative sample were obtained, a fact highlighted in previous work by the same authors (Sovani et al, 2008, in press) but also showing that no major gender differences exist in the data obtained. Gender differences are truly negligible, with the usual slight male edge in performance tasks and slight female edge in verbal ones. With regard to the intercorrelations, seen in Table III, it is clear that the two Archives of Indian Psychiatry 8(2) October 2007
traditional All the other indices do correlate significantly with one another, since the WISC IV is essentially a test of the g factor, as per the definition of intelligence used by the author. However, the orthogonality and unique variance contributed by each separate subtests is clear from the moderate values of correlation obtained. Table II presents some important data reflecting the slight edge female respondents have over male subjects in the study in terms of scoring on each index. Except for the female respondents standard deviation of scores on the Verbal Comprehension Index and the Full scale IQ, most other data closely approximates normative values of a mean of 100 and a standard deviation of 15. Work reported previously discusses these close-tonormative trends in more detail. It is important to 51
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Anuradha Sovani et al : Wechsler Intelligence Scale for Children, IVth edition establish that a test is truly culture fair, before beginning to use it in another cultural setting different from the one in which it was created. This attempt has been made by the authors of this study, since re-norming the entire test in India would prove a long drawn out and expensive venture, further delaying proposed use of the test in our country. Discussion of results below highlight the value of these findings while attempting to use the WISC IV in Indian settings. Discussion: It is interesting in this paper to see the Full scale IQ based on the tested sample of 221 children and adolescents emerge as 100.74, with a standard deviation of 15.49. If the small sample tested could yield a mean and standard deviation so close to the normative sample, certainly a larger and more geographically representative sample would perhaps yield even more valid findings. In contrast, it is also possible that this close approximation to the available norms is achieved in this study only because Mumbai yields a very cosmopolitan, English educated sample, which may perhaps not be replicable in another, slightly smaller Indian city. Hence, the results may be generalized with care, or preferable replicated elsewhere. Inter-correlations between indices Table III) are also very much in keeping with the cognitive model of intelligence on which the WISC IV is based, which assumes a general factor, and several specific factors assessing different areas of ability. The WISC IV could thus now be used in Indian settings, albeit with caution, and perhaps more attempts be made to seek permission of test publishers to yield Indian language adaptations of the test. Earlier work by this research team has shown that the match between the normative distribution as represented in the original manual of the WISC IV and the data from the sample of N=211 studied in this multicenter study shows an excellent match. It is thus clear, that Mumbai being a large, cosmopolitan, metropolitan city, closely matches the pool of subjects drawn by the very representative stratified sample drawn by the original test authors, adequately enough to use the norm tables as they are in this city. The only caution to be cited here, is that this may hold true only for children who speak and are educated in English, since instructions, as well as A. Sovani, S. Thatte, R. Korde K. Joshi, H. Shroff,S. Savant A. Satyanarayana, S. Ravi, P. Saraff Corrospondence: Dr. Anuradha Sovani OM, 31, Shreesh Society, LIC Cross Road, Off. Eastern Express Highway, Thane-400 604, Maharashtra, India. Phone : 25833661 (M) 98210 50528 E-mail : anuradhasovani@gmail.com 52
subtests like Vocabulary would certainly be affected with a vernacular medium student being tested by the original test. The data presented in this paper should set psychologists minds at ease about using the WISC IV for English educated children in the city of Mumbai, and perhaps generalizable to other similar metropolitan cities. Testing for Learning Disabilities is a large portion of the burden of testing of State recognized testing centers in Mumbai city, and the utility of the WISC IV in yielding important indices like those for Verbal Comprehension, Perceptual Reasoning, Working Memory and Processing Speed, may lead to very relevant interpretations in profiling the child with LD. A further advantage of using the WISC IV, by psychologists themselves, and also referrals for assessments by other mental health professionals, would be that the authors of the test have taken care to document its use for a number of special populations such as young people with Mental Retardation (MR), Attention-Deficit / Hyperactivity Disorder (AD/HD), Learning Disabilities (LD), both AD/HD and LD, and Traumatic Brain Injury (TBI). (Wechsler, 2003) The paper may be critiqued freely by readers for more pointers to take the study further, and be treated as an invitation to add to the data pool, making the study even more valid and publication worthy in the future, by sending their contributions to the already existing data pool with IPH. (website: www. healthymind.org, email: iph@healthymind.com).
References
1. Sovani, A.V. and Bodas, J. (2001) A comparative study of WISC norms, a new methodology. Paper presented at International Conference of Cross Cultural Psychology, December, 2001, and published in Proceedings. Sovani, A.V. (2002) Relevance of IQ testing in the assessment of Learning Disabilities, Asian Journal of Pediatric Practice, 6(2), 45-49. Sovani A.V. , Thatte, S. Shroff, H., Sawant, S., Sathyanarayanan, A., Ravi, S., Joshi, K., , Korde, R., Saraff, P. (2008. in press) Wechsler Intelligence Scale for Children, IVth edition-An exploratory study from Mumbai. Wechsler, D. (2003) Wechsler Intelligence Scale for Children- IV. The Psychological Corporation, Harcourt Assessment, Inc.
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Original Article
Depression and Anxiety Disorder in Primary care

Jahnavi Acharya Abstract
Background: About 15-20% of all patients who seek help in general practice do so for emotional and psychosocial problems. The commonest are depressive and Anxiety disorders. Many of these cases go undetected. A structured tool for recognising common psychiatric morbidity in primary care will help GPs to recognise these illnesses This study was conducted to study prevalence of depression and anxiety disorders in primary care and to study socio demographic characteristics, relevant clinical history and common clinical manifestations of patients with depression or anxiety disorders.This study was conducted to study prevalence of depression and anxiety disorders in primary care and to study socio demographic characteristics, relevant clinical history and common clinical manifestations of patients with depression or anxiety disorders. Setting: Two hundred patients attending General Practice outpatient were interviewed using MiniInternational Neuropsychiatry Interview (M.I.N.I.) primary care version. Method: First stage i.e. screening all patients were given screening questions in Gujarati. Second stage i.e. Diagnosis,thephysicians were asked to present the confirmatory questions if required. All patients were then interviewed forthe evidence of psychiatric morbidity by the interviewer. Diagnosis was made using DSM-IV. Results: Depressive and anxiety disorders were diagnosed in 34(17%) patients. M.I.NI. has sensitivity 100%, specificity98%, positive predictive value 94%, and negative predictive value 100% in this study. Patients from lower socioeconomical class, living in rural areas, married, and belonging to joint family were more commonly affected by these diseases. Substance consumption was more among those who had anxiety or depression. Conclusion:In this study 17% of primary care patients were diagnosed as having depression or anxiety disorders. MINI has high sensitivity in identifying depression and anxiety disorder when used by primary care physicians. Key words: Depression, Anxiety disorders, Mini International Neuropsychiatry Interview
Introduction Depression and Anxiety disorders are responsible for considerable disability worldwide. The WHO Global Burden of Disease Survey estimates that by the year 2020, major depression will be second only to ischemic heart disease in the amount of disability experienced by sufferers. Apart from functional impairment and inordinate morbidity these disorders are known to cause high use of health services.1 Considering the paucity of the specialists services in mental health care system 2 the burden of the management of the psychiatric illnesses is going to fall on primary care physicians shoulders. Even National Mental Health Programme in India has integrated primary care system into mental health care. Since the pioneering study of psychiatric morbidity in primary care by Shepherd et al,(1966 )3 it
has become increasingly apparent that a substantial proportion between 20-25% of patients consulting general practitioners are suffering from some form of psychiatric morbidity. 5 It is said that a general practitioner who sees 40 patients a day can expect that 8 patients will require support or treatment for anxiety and depression and that is not counting those whose disorders go unrecognized. 6 In a study of 200 general practitioners in Bangalore, Shamasunder (1978) reported that 65% GPs found psychiatric morbidity less than 10% in their practice while 24% reported a figure less than 20%. In another survey using in Bangalore city GPs could identify only 25% of probable cases. 7 This reflects the degree to which the GPs are aware about mental illness. Though 90% GPs admitted seeing

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Jahnavi Acharya : Depression and Anxiety Disorder in Primary care psychiatric patients in their practice in survey of Jaipur city and the attitude towards the patients was negative in large numbers of GPs 8. The primary care physicians generally have difficulty in determining neurotic illnesses 9 To increase the rate of recognition, the family physicians need efficient ways to diagnose psychiatric diseases. The diagnostic manual used by mental health professionals DSM-IV or ICD-10 has limited usefulness for GPs. 10 Several in-office assessment instruments have been developed to use in primary care which are easy to use with high validity. Due to time constraint they can not be applied to all patients. One option would be to use them in high risk group. Study of sociodemographic variables of a particular disease would be helpful in determining at-risk group 9 With this in mind present study was done with the objectives of finding out prevalence of depression and anxiety disorders in primary care, to study sociodemographic characteristics and relevant clinical history of the patient with depression or anxiety disorders, to find out common clinical manifestations of depression and anxiety disorders in primary care settings. Method: 200 patients attending Curative Preventive and General Practice (CPGP) Outpatient Department, Shree Sayajirao General Hospital, Baroda for the first time were selected as study population. All patients attending this general hospital pass through filter of CPGP, hence it is very similar to primary care setting. Those below twelve and requiring urgent specialist care were excluded. Sociodemograhic data of each patient recorded systematically in the semi-structured proforma by the primary care physicians. A questionnaire based on Mini International Neuropsychiatric interview (M.I.N.I.) as proposed by the International consensus group on depression and anxiety disorders was used to identify the most prevalent conditions in primary care: depression, panic disorder, social anxiety disorder, generalized anxiety disorder and posttraumatic stress disorder. 12 Many diagnostic instruments have been developed for use in primary care such as primary care evaluation of mental disorders (PRIME-MD), symptom driven diagnostic system for primary care (SDDS-PC), GHQ, Centre for epidemiologic studies depressed mood scale (CES-D). These instruments have their advantages and disadvantages. For example PRIME MD explores only limited spectrum of disorders. Moreover it has been found less useful in disorders other than mood disorders in primary care. GHQ appears to be useful in those most severely affected and it is not diagnosis specific. Many others are time consuming to complete and score. This was background for developing MINI which was 54
developed jointly by psychiatrists and clinicians in the United States and Europe; for DSM-IV and ICD 10 psychiatric disorders. It has high sensitivity, specificity as well as positive predictive value for depressive and anxiety disorders when compared against such gold standard as CIDI and Structured clinical interview for DSM III R. the screening questions take only 5 to 10 minutes to complete. Diagnostic concordance was high with specialists for almost all disorders. In first stage i.e. screening all patients were given screening questions, which were presented to them in Gujarati. These short, high yield questions take 5-10 minutes to complete. The patients were instructed to respond in yes or no and mark their responses accordingly in the sheet presented to them. In case of illiterate patient a volunteer was requested to present these questions to the patient and mark the responses. In second stage i.e. Diagnosis, the physicians were asked to present the confirmatory questions if the answer to screening questions prompted an index of suspicion for presence of illness. They were also asked to give their impression regarding diagnosis and send patient to psychiatry OPD. Clinical Interview: All patients were then interviewed for the evidence of psychiatric morbidity by the interviewer who was blind to the primary care physicians opinion. The interviewer followed standard protocol for psychiatric history taking and mental state examination. Diagnosis was made using Diagnostic and Statistical Manual of Mental Disorders, 4th edition (1994). Patients with anxiety or depressive disorders on clinical interview were considered index group and those who did not have these disorders were considered control group. Demographic characteristics of both the groups were compared, chi-square andt test applied as appropriate. Analysis of data was done using SPSS (Statistical Package for Social Sciences) software of statistical analysis. Results: On clinical interview out of 200 patients studied psychiatric morbidity rate observed was 19.5%. Depressive and anxiety disorders were diagnosed in 34(17%) patients. Among them more common were depressive disorders which were present in 18(9%) patients. 10(5%) patients were suffering from one or the other anxiety disorders and 6(3%) patients were having co morbid anxiety and depressive disorders. In primary care physicians opinion 36(18%) patients had anxiety and/or depressive disorders. Out of them 20(10%) were suffering from major depressive disorder, 10(5%) patients had anxiety disorders and 6(3%) patients were having both anxiety and depression. Archives of Indian Psychiatry 8(2) October 2007
Jahnavi Acharya : Depression and Anxiety Disorder in Primary care Table 1 : Comparison of primary care physicians opinion with clinical
Table 2 Frequency of individual disorders as observed in clinical interview and in primary care setting
Disease PCPs Opinion (N=200) N(%) 20 (10) 4(2.0.) 3 (1.5) 1 (0.5) 2 (1) Clinical Interview (N=200) N(%) 18(9) 3 (1.5) 4(2) 1 (0.5) 2 (1)
Depressive disorders Panic disorders Generalized Anxiety Disorder Post-Traumatic Stress Disorder Social phobia
PCP : Primary care physician
As shown in Table 1 primary care physicians could diagnose almost all cases of anxiety and depression. The diagnostic instrument they were given has sensitivity 100%, specificity 98%, positive predictive value 94%, Married, those belonging to joint family and living in negative predictive value 100%. rural areas were overrepresented in diseased group. 80% Clinical interview Clinically, among 18 patients having depressive of the index group was earning less than 1000 Rs per disorders, Major depressive disorder was an appropriate month and majority of them were unskilled workers.Age, Anxiety depression Anxiety depression diagnosisMINI in 12 patients. While 4 patients were present and education level did not differ significantly only sex absent having adjustment disorder with depressed mood and in 2 between both the groups. patients, mood disorder with prominent depressive One patient in the index group had episode of features was present Anxiety depression induced by substance or general medical 34 2 major depression in past, while none of the patients had condition. Similarly alcohol induced anxiety disorder was past history suggestive of anxiety disorders. Two Anxiety depressionpatients. These could not be differentiated 0 164 present in 2 absent patients who were suffering from depressive disorders by the instrument used. had past history of Tuberculosis. None of the patients had first degree relative suffering Anxiety disorder and depression were coexisting anxiety disorders, while family history of depressive in 6 patients as appeared clinically and in primary care disorder was present in 2 patients of depression. Family setting. All but one patient received similar diagnosis by history of substance dependence was positive in 3 PCP and clinical interview. patients, whose fathers had alcohol dependence. Family Socio demographic characteristics of Index and history of suicide was present in one patient who was Control groups are compared in Table 3 suffering from generalized anxiety disorder (GAD) Out of 200 patients majority of them were male currently. (53.5%), young adults (mean age: 36.9), married (75%), Statistically significant difference was found belonging to joint family (58%) and residing in rural areas among index and control group as regards substance (51.5%). use. Out of 200 patients 68(34%) patients were consuming one or other substance. Nicotine abuse was Half of the patients were illiterate or had received present in 46(23%) patients. 14(7%) patients were only primary level of education. More than one third of abusing alcohol; 6(3%) patients were using both nicotine them were earning living by unskilled work. Monthly and alcohol. One patient abused opioids. Those with income of more than two third of the patients was less identifiable depressive or anxiety disorders were abusing than Rs.1000. When these characteristics were compared among Archives of Indian Psychiatry 8(2) October 2007
index and control groups statistically significant differences were observed in relation to income, occupation, marital status, family constellation and residence.
55
Jahnavi Acharya : Depression and Anxiety Disorder in Primary care
Table 3: Sociodemographic Characteristics

Characteristics Psychiatric disorder present (n=34) N,% 12-75 36.9(14.9) Psychiatric disorder Absent (n=166) N,% 12-75 37.9(15.2) P=
Age (in yrs.) Range Mean (SD) Sex Male Female Education Illiterate Primary Secondary Higher secondary Graduate Occupation Housewife Unskilled worker Retired Student Business Service Unemployed Income Rupees <500 500-1000 1001-1500 1501-2000 >2000 Marital Status Married Unmarried Divorced Widowed Residence Rural Urban Type of Family Joint Nuclear
17 (50) 17 (50)
90 (54.2) 76 (45.8)
p=0.7
13 (38) 4 (12) 6 (18) 9 (26) 2 (6)
58 (35) 16 (10) 50 (30) 38 (23) 4 (2)
p=0.6
8 (23.5) 12 (35) 0 3 (9) 1 (3) 6 (18) 4 (12)
48 (29) 60 (36) 5 (3) 18 (11) 8 (5) 25 (15) 2(1)
p=0.03
13 (38) 15 (44) 1 (3) 1 (3) 4 (12)
75 (45) 51 (31) 13 (8) 15 (9) 12 (7)
p=0.04
23 (68) 9 (26) 0 2 (6)
127 (76.5) 27 (16) 3 (2) 9 (5)
p=0.04
24 (67) 10 (33)
79 (49) 87 (51)
p=0.014
p=0.021 23 (68) 11 (33) 93 (56) 73 (44)
56

Jahnavi Acharya : Depression and Anxiety Disorder in Primary care alcohol and nicotine more frequently. Moreover 3(1.5%) patients had substance induced mood or anxiety disorder. The control group patients also had features of depression or anxiety. 34(17%) patients had complaint of sadness of mood but only 26(13%) patients had either depression or anxiety disorders. 8(14%) patients were not fulfilling criteria for any major disorders. Second most common symptom among control group was loss of interest or pleasure (3.6%). Complaints such as loss of appetite, easy fatigability; panic like symptoms; sleep disturbance; factures of social anxiety and excessive worries were also present among control group. None of the patients had suicide attempt or suicide plan. Apart from depressive and anxiety disorders; 2(1%) patients had schizophernia; 1(0.5%) patients was having sub-average intellectual functioning; 1(0.5%) patient was dependent on opioid and 1 (0.5%) patient was suffering from somatization disorder when interviewed clinically. In 2% appropriate DSM-IV diagnosis was adjustment disorder; while in another 2% depression was secondary to medical illness or substance use. Similarly 1% had anxiety disorders induced by the substance. The instruments used in primary care setting usually lack consideration of such important axis as physical illness in its definition of a disease. This exerts a powerful influence on a clinicians case-making decision 9. The instrument providing guidelines to differentiate primary or secondary form of diseases may be more useful to avoid such error. Secondly, as earlier observed by Shephard et al. (1983) 4 the way symptoms are elicited affect the diagnosis. If the primary care physicians would have been trained to apply the questionnaire and in the self report screening questions phrases like whole day., every day and other duration criteria would have been highlighted, so that patient would mark them yes only if symptoms were persistent and pervasive; this error could have been avoided. Proper diagnosis can save patient from unnecessary long-term pharmacological treatment and their untoward side effects. Nonetheless identifying these milder varieties of anxiety and depressive disorders in primary care is of utmost importance. The first contact physician is easily accessible and can offer these patients either psychological or pharmacological treatment or both using various guideline. 3% of the patients in this study were suffering from comorbid anxiety and depressive disorder. Major depressive disorder was coexisting with one of the anxiety disorders. Virtually all studies have reported high rates of comorbid depression and anxiety disorders. In present study 50% of the patients with social phobia; PTSD and panic disorders had comorbid major depressive disorder. The resulting disability and burden affect not only the individual in terms of decreased productivity but the level of health care utilisation is also increased. 20 Psychiatric morbidity is frequently linked with lower socio-economic level 15 In a recent study in Southern Indian city Indicators of low socio-economic status (being in debt, inability to buy food, having less than three square meals per day) and illiteracy were found to be significantly associated with psychiatric morbidity.21 In present study statistically significant difference was observed in relation to income and occupation. 80% of the index group were earning Rupees 1000 or less per month; majority of them were unskilled workers. Those who are single, divorced or widowed have higher prevalence of depressive and anxiety 57
Discussion
In this study 17% of primary care patients were diagnosed as having depression or anxiety disorders. 9% of them were diagnosed as having depressive disorders and 5% of the patients as having one or the other anxiety disorders. 3% of them had comorbid anxiety and depression. The WHO study on psychological disorders in primary care reported rate of depressive disorders 11.7%; that of anxiety disorders 10.5% and comorbidity of depressive and anxiety disorders 4.6%. The PRIME-MD 1000 study 13 detected prevalence of depressive disorders (MDD and Secondary depressive disorders) 14%, that of any anxiety disorders 18%. Another large scale WHO collaborative study in general health care using primary care version of CIDI (Composite International Diagnostic Interview) in 14 countries reported depressive disorder in 10.5% and anxiety disorders (Panic disorder, agoraphobia and generalized anxiety disorder) in 10.5% 14 Rates obtained in present study are less as compared to previous large scale study which may be due to small sample size, more stringent criteria used to diagnose these disorders. As per primary care physicians opinion 18% of the patients were suffering from depression or anxiety disorder. 10% were of major depressive disorder, 5% were of anxiety disorder and 3% were suffering from simultaneous presence of both the disorders. Though findings are very similar to those obtained by clinical interview, not all patients diagnosed as having major depressive disorder were having MDD

Jahnavi Acharya : Depression and Anxiety Disorder in Primary care disorders. In this study both the disorders were common among married. Homemakers constituted second major group after unskilled workers among diseased population. In India higher morbidity has been observed in the married as compared to single 15. Of the married, the housewives were more prone to develop neurosis than those who are single 15. Marriage at an early age being not uncommon in India carries the risk of early pregnancy and the responsibility of a child in addition to multiple roles that the homemaker is expected to fulfill. Such life situation makes her more vulnerable to stressful or frustrating situations. For the males the stress of economic competition falls more heavily 15. Moreover those living in rural areas were overrepresented in this study; and statistically significant difference was observed between two groups regarding family type and residence. Those belonging to joint family and living in rural area were more commonly affected by the disorders; while earlier studies reported urbanization and nuclear family constellation as risk factors for development of psychiatric illnesses. As the hospital where the study was conducted majority patients come from rural areas as well as from Madhya Pradesh and Rajasthan (particularly in morning hours number of patients coming from rural areas are more). The study was conducted in morning hours which partly explains predominantly rural population in this study. People coming from city areas prefer late hours for consultation. In Indian villages joint family type is still prevalent. This explains the more number of patients from joint family in this study. Though the significant difference observed with regards to these two variables among index and control groups requires further validation by large scale study. It is said that men express their distress in different way; through violence or substance use 9. They often take alcohol or smoke as relieving measure. Moreover these substances are responsible for inducing mood and anxiety disorders. In present study alcohol and nicotine use were significantly more in index group. 1.5% of the patients had substance induced mood or anxiety disorder while 34% of the patients were abusing one or the other substance. None of the patients in present study had past history or family history of anxiety disorders. Only one patient with MDD had past history of MDD and 6.6% of depressed patients had family history of depression. This suggests that depression and anxiety disorders are more reactive than biological in this study, which was also observed in earlier studies. Present study also reports presence of depression and anxiety features in patients who did not have identifiable psychiatric illnesses. Presence of 58
subsyndromal or nonspecific affective symptoms has been observed in primary care settings by many primary care researchers. 42% of the patients reported symptoms suggestive of psychiatric illness but did not receive any psychiatric diagnosis in the PRIME-MD 1000 study. 13 Barret et al. (1988)17 also noted nonspecific subsyndromal or mixed conditions in primary care clinics. Symptoms such as depressed mood, anhedonia, sleep disturbance, anorexia and weight loss, easy fatiguability and panic like symptoms were commonly seen among control group. These symptoms have low discriminatory power i.e. they cannot differentiate depressed from non-depressed and cause problems in diagnosis 16 Though none of the patients had past history of suicide attempt, and none of them had suicide plan; suicidal ideation or death wish was present in 7% of the patients. Earlier study reported 2.6% rate of suicidal ideation in primary care 18. The rates in present study are quite high as compared to the earlier study and suggest severity of these disorders. There are few limitations of this study worth mentioning. Sample size is small. Results cannot be generalized as there is overrepresentation of patients from lower socio-economic class, rural areas and with low education level. Primary care physicians could have received more training to avoid inaccuracy in diagnosis.
Summary and Conclusions

Out of 200 patients (103 men, 97 women) studied for depressive and anxiety disorders in primary care 34(17%) patients had depressive or anxiety disorders. Primary care physician could diagnosed almost all cases of depression and anxiety disorder using two stage approach recommended by International Consensus group on depression and anxiety disorders applying questionnaire based on Mini International Neuropsychiatric Interview (MINI) version 5.0. Significant differences were observed in relation to income, occupation, marital status, family constellation, residence as well as substance consumption when patients with and without anxiety and depressive disorders were compared. Minor symptoms of depression and anxiety were frequently observed among those who did not have depression or anxiety disorders. Acknowledgement I am indebted to Dr Usha Goswami and Dr G.K.Vankar for their invaluable assistance and constant encouragement in accomplishing this study.

Jahnavi Acharya : Depression and Anxiety Disorder in Primary care
References:
1. Lecrubier Y. (2001) The Burden of Depression and Anxiety in General Medicine. Journal of Clinical Psychiatry; 62(Suppl.8):49 (discussion10-1). 2. Neki J S (1973); Psychiatry in South East Asia: British Journal Of Psychiatry; 1973 Sept 123(574). 3. Shepherd M (1965) Epidemiology & mental disorder: The Scientific basis of medicine annual review 1965: 299-315. 4. Shepherd Michael (1995). Primary care Psychiatry: Health Services Research is not enough. British Journal of Psychiatry, 166: 1-3. 5. Goldberg, Blackwell (1970):Psychiatric illnesses in general practice: A detailed study using a new method of identification: British Medial Journal 1970 May 23; 1(5707) 439-4 6. Ellen S.R., Norman T.R., Burrows G.D. (1998).Assessing Anxiety and Depression in Primary Care. Medical Journal of Australia (an article published on internet). 7. Shamsunder C, Krishnamurthy S, Prakash O M, Prabhakar N, Krishna D K; Psychiatric morbidity in a general practice in an Indian city. British Medical Journal 1986:292 1713-5. 8. Gupta I.D., Gautam S., Kamal P. (1992). GPs Attitude towards Psychiatric Disorders and Psychiatric Patients: A Survey of Jaipur City. Indian Journal of Psychiatry, 34:140-144. 9. Blacker C.V.R.; Clare A.W. (1987). Depressive Disorder in Primary Care. British Journal of Psychiatry. 150:737-751. 10. Pingitore D., Sansone R.A. (1996). Using DSM IV Primary Care Version Guide to Psychiatric Diagnosis in Primary Care. American Family Physician, October 1996. 11. Mcquaid J.R., Stein M.B., Mccahill M, Laffaye C., Ramel W. (2000). Use of Brief Psychiatric Screening Measures in a Primary Care Sample. Depression and Anxiety, 12(1):21 9. 12. Ballenger J.C., Davidson J.R.T., Lecrubier Y. Nutt D.J. (2001). A Proposed Algorithm for Improved Recognition and Treatment of the Depression/ 13.
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Anxiety Spectrum in Primary Care. Primary Care Companion Journal of Clinical Psychiatry, 3, .44-52. Spitzer Rl., Williams J.B.W., Kroenke K., Linzer M., Frank Verloin, Hahn S.R., Brody D., Johnson J.G. (1994). Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care. The PRIME-MD 1000 study. Journal of American Medical Association, 272, P.1749 1756. Ormel J., Vonkorff M., Ustun Berdirhan, Pini S., Olddehinkel T., et al. (1994). Common Mental Disorder and Disability across Cultures. Journal of American Medical Association. 272:1741 1748. Sethi B.B., Manchanda R. (1978).Socio-economic, Demographic and Cultural correlates of Psychiatric Disorders with Special Reference to India. Indian Journal of Psychiatry. 20:.199-211. Amin G. (1995). Depression in Primary Care. Dissertation Submitted to Maharaja Sayajirao University, Baroda; Department of Psychiatry, Medical College & S.S.G.H. Baroda (1995). Barrett J E; Barrett J A; Oxman T E; Gerber p d (1988) prevalence of psychiatric disorders in primary care practice: Archives of General Psychiatry, 45:1100-1106. Cooper-Patrick, Crum R.M., Ford D.E. (1994) Identifying Suicidal Ideation in General Medical Patients, JAMA. 272: Sheehan D.V., Lecrubier Y., Sheehan K.H., Amorim P., Janavas J., Weiller E., Hergueta T., Baker R., Dunbar G.C. (1998).The Mini Internatinal Neuropsychiatric Interview (M.I.N.I.): the Development and Validation of a Structured Diagnostic Psychiatric Interview for DSM IV & ICD-10. Journal of Clinical Psychiatry, 59 (Suppl. 20), 22-33. Lepine J P(2001) Epidemiology, Burden and Disability in Depression and Anxiety:Journal Of Clinical Psychiatry, 62(Suppl 13); 4-10 discussion 11-2 Pothen M, Kuruvilla A, Phillip K, Joseph A, Jacob K S. Common mental disorders among primary care attenders in Vellore South India: Nature, Prevalence and Risk factors. Int Journal of Social Psychiatry 2003 June 49(2) 119-25.
Correspondence: Jahnavi Y. Vasavada-Acharya Flat 5A Bhavya 39 Mahalxami Utsav complex Kunnour High Road Aynavaram Chennai 600 023 Phone: 044 - 26744050 jahnaviyv@yahoo.co.in M.D.( Psychitry)

59
Case Report
Conversion Disorder Presenting As Non-Epileptic Seizures : A Case Report

Himanshu Sharma Nimisha Desai
Abstract Non-epileptic seizures (NES) are one of the most common motor manifestations of conversion disorder. To make a diagnosis of NES is difficult even for best epileptologists. Conversion disorder is very common psychiatric condition found in young unmarried girls of lower socioeconomic status living in a joint family who have been exposed to child (sexual) abuse. Presence of stressor is common. Here we present a case of a young male with conversion disorder presenting with NES. Key Words: Conversion disorder, Nonepileptic seizures (NES), stressor, male sex Introduction Non-epileptic seizures (NES) which are a common presentation of Conversion disorder are known by multiple synonyms: Pseudo epileptic seizures, Non epileptic attack disorder (NEAD) and psychogenic seizures, etc [1-4]. To make a diagnosis of pseudo seizures is difficult even for best epileptologists. Pseudo seizures are seen in 20% of those patients referred to epilepsy clinics. [1] The most common predisposing or precipitating factors were trauma (78%).Common perpetuating factors were family dysfunction (54.2%) and affective disorder (42%). [5] Several conditions can mimic or cause NES viz. epilepsy, migraine, tic disorder, vestibular disorder, TIA, MS, sleep disorder, hypoglycemia, syncope, arrhythmias. Among psychiatric disorders anxiety, depression, conversion, somatization, factitious disorder and malingering come in the differential diagnosis. NES accounts for 25% of all cases of Conversion disorder [1, 2, 6] . In India, a high occurrence of these episodes have been reported in young adults from lower socioeconomic class, joint family & significantly high in females. The affected persons are mostly teenaged females with h/o sexual abuse or trauma. [ 6, 7] Case History Patient A.K, a 24yr old well-educated male from upper socioeconomic status was admitted to the medical ward of our hospital with h/o multiple convulsions for past 15days before admission. Patient was asymptomatic 15 days back when he had one convulsion lasting for 10minutes followed by 10minutes of confusion. There was no up rolling of eyeballs, no frothing from the mouth, no tongue biting, and no urinary or fecal incontinence. On the day of admission patient had a similar episode in which he reportedly fell down and received injury to his left temporo-occipital region. There was no h/o loss of consciousness/ nausea/vomiting//fever or h/o any drug intake or withdrawal. The patient was also found to have freshly diagnosed hypertension for which T. Nifedipine 10mg tds was started. Ophthalmologic examination revealed grade I-II HTN changes and AV nicking. Patient 60
was loaded with Eptoin. and Inj. Dexona and Inj. Mannitol IV stat were given .T. Mazetol 200 mg 1 tds and T. Rivotril 1 mg bid were also started. Since the patient was not responding to standard antiepileptic treatment and the pattern of his seizures kept on changing a psychiatric referral was sought. In a detailed interview to the psychiatrist the patient did not reveal much but on a Narco interview he revealed that his wife had an affair before marriage, which she revealed to him on the first night. He was very much distressed about this. He used to doubt his wifes character despite her repeated reassurances that she was faithful to him. This probably acted as a stressor, which brought about the pseudo seizures. Patient also reveled that he was also in love with one girl before marriage and wished to marry with her but she ditched him. Patients grandfather was hypertensive and had h/o CVA and had several episodes of GTCS before he died which the patient watched as a child.This may have affected him adversely as he was very much attached to his grandfather. Patient was a gutkha (tobacco) chewer. There was no h/o any other medical or psychiatric illness in the family. The physical examination was normal. All routine investigations were normal, including CT scan of head and neck region. Video EEG monitoring was confirmatory of pseudo seizures since there was jerking of the torso and flailing of arms during the recording and there was no loss of consciousness, which did not conform to any sort of epileptiform activity. On mental state examination patient was conscious, cooperative, sitting quietly on bed, He stared into the space whenever examiner tried to talk about the stressor and often would start to cry. Occasionally he got a pseudo seizure, the pattern of which differed each time. Ideas of infidelity were present .No perceptual abnormality was detected. According to DSM-IV-TR a provisional diagnosis of Conversion disorder with seizures or convulsions was made. [ 8] Patient was put on T.Sertraline 50mg 1hs and T.Clonazepam 0.5mg 1hs and twice weekly insight oriented short-term psychotherapy and marital therapy sessions were also started. During psychotherapy sessions the interpersonal conflict was Archives of Indian Psychiatry 8(2) October 2007
Himanshu Sharma, Nimisha Desai : Conversion Disorder Presenting As Non-Epileptic Seizures brought out at the conscious level and was resolved successfully. Thereafter, patient improved with this treatment and was stable at the end of 2 months & continued his improvement in successive follow-ups. Discussion Conversion disorder is a subtype of somatoform disorder and it reflects a hypothesis that an unconscious psychological conflict is converted into symbolic somatic symptoms, thus reducing anxiety and shielding the affect from painful emotion. [9] According to one study conversion disorder occurs mainly in young women (92.5%) but may also be found in (7.5%) males.[7] It was also noted that motor symptoms comprising (87.5%) were the commonest presentation of which (74 %) had pseudo seizures. In a study of the semiology of seizures in NES patient it was found that of the 17 patients studied, 1male (17.1%) patient had GTCS as presentation and had an underlying stressor. [10] Also (40%) had family related problems and (30%) had love related problems. The prevalence of the disorder is highest in rural areas and among the undereducated and the lower socioeconomic classes. [7] In this case report the patient was a well-educated male belonging to upper socioeconomic status. The seizures occurred in presence of audience [ 3, 11] There was presence of stressor of premarital affair of his wife. Love Affair of the spouse was reported to be present in 30 % of cases in one recent study. [7] Also, patient had the sad experience of losing his girl friend to someone else in marriage. There is evidence of Role Model evoked where the patients with conversion disorder may unconsciously model their symptoms on someone important (in this case the grand father) to them [7] The patients failed love affair, his grandfathers seizures and his wifes premarital affair all unconsciously affected the patients psyche and resulted into non-epileptic seizure (NES). The seizures showed a variable pattern due to which they were miscued as GTCS earlier and anti epileptics (AEDs) were started which were ineffective. This finding matches with other studies. [1, 2, 12] The recording of seizures by video EEG telemetry was confirmatory in our case as shown by other studies [11] . Many interventions like Psychotherapy (Insight oriented short term psychotherapy and marital), behavior therapy (biofeedback, relaxation), Drugs (anxiolytics &antidepressants) and Hypnosis have been used with different amount of success for treatment.[12] In conclusion, non-epileptic seizures/pseudo seizures may be a diagnostic dilemma and may lead to over prescription of AEDs. So, the treating physician should take great care to rule out the psychiatric etiology Sources of support: None Dr. Himanshu Sharma*, Associate Professor and Head, Dr.Nimisha Desai, Assistant Professor Department of Psychiatry, Pramukh Swami Medical College & Shri Krishna Hospital, Karamsad 388325, Anand, Gujarat e-mail:himanshu1969@rediffmail.com (M): 09879468465 * Correspondence Archives of Indian Psychiatry 8(2) October 2007
before arriving at a medical diagnosis. References 1. Bhatia M S, Pseudo seizures (Review article) Indian Pediatrics 2004:41:673-679. 2. Duncan.J S, Shroven.DS, Fish.DR, Psychological and psychiatric aspects of epilepsy, in CLINICAL EPILEPSY; B.I Churchill Livingstone Pvt Ltd, New Delhi 1996, Chapter 9, 321-48. 3. Lesser RP. Psychogenic seizures. Neurology 1996 ; 46:1499. 4. Gates JR: Epidemiology and classification of nonepileptic events. In Non-Epileptic Seizures. Eds. Gates JR, Rowan AJ. Boston: ButterworthHeinemann 2000: 3-14. 5. Reuber M, Howlett S, Khan A, Grunewald RA, Non Epileptic Seizures and Other Functional Neurological Symptoms: Predisposing, Precipitating, and Perpetuating Factors. Psychosomatics, MayJune 2007 ;( 48:3,): 230-38. 6. Alper K, Devinsky O, Perrine K, Vazquez B, Luciano D: Nonepileptic seizures and childhood sexual and physical abuse. Neurology 1993; 43:1950-53. 7. Deka K, Chaudhary P, Bora K, Kalita P, A study of clinical correlates and sociodemographic profile in conversion disorder. Indian J Psychiatry, Jul-Sep 2007, 49(3): 205-7. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4ed Text revision, Washington DC 2000. 9. Devinsky O, Editorial Commentary- Nonepileptic psychogenic Seizures: Quagmires of Pathophysiology, Diagnosis and Treatment, Epilepsia 1998; 39(5): 458-62. 10. Gigineishvili D, Clinical semiology of psychogenic nonepileptic seizures. Annals of Biomedical Research and Education, October-December 2005; 5(4): 277-80. 11. Kanner AM, Stagno S, Kotagal P, Morris HH: Postictal psychiatric events during prolonged videoelectroencephalographic monitoring studies. Arch Neurol, 1996:253-58. 12. Mendez M F; Neuropsychiatric Aspects of Epilepsy. Chapter 2.4, Neuropsychiatry and Behavioral Neurology. In: Kaplan & Sadocks Comprehensive Textbook of Psychiatry; 8th Edition, Sadock BJ, SadockVJ, editors. Lippincott William and Wilkins: Philadelphia; Vol.1, 377-90. 2000.
Conflict of Interest: None
61
Case Report
Promethazine induced Neuroleptic Malignant Syndrome in a patient with Bipolar Affective Disorder
Yvonne S. Pereira Ashish Srivastava Melvin CSilva
Abstract: A male patient with bipolar affective disorder who developed neuroleptic malignant syndrome following treatment with promethazine is reported. This case report emphasizes the importance of being cautious when using promethazine in patients with neurological illnesses. Key Words : Neuroleptic Malignant Syndrome, Promethazine. Introduction: Delay and Deniker first described neuroleptic malignant syndrome in 1968. It is a potentially life threatening idiosyncratic reaction to neuroleptics and other drugs affecting dopaminergic transmission. It has been reported in patients receiving metaclopromide, prochlorperazine and droperidol.1 Central nervous system compromise is found to increase the risk of developing neuroleptic malignant syndrome.1 The syndrome tends to develop when neuroleptic treatment is initiated, or the dose is rapidly increased, particularly when the dose is high or parenteral. The pathogenesis of neuroleptic malignant syndrome is mainly attributable to dopamine blockade, 1-3 and dysregulated sympathetic system hyperactivity is responsible for most features of neuroleptic malignant syndrome.4 Neuroleptic malignant syndrome may present suddenly but more often the course is indolent, with autonomic hyperactivity and unexplained episodic tachycardia and blood pressure fluctuations observed early. 5 Altered consciousness is considered by some to be sine qua non for the diagnosis of neuroleptic malignant syndrome.6 The following case report describes a bipolar patient who developed this condition solely due to promethazine. The case: Mr. A.N. , 54 years old married male had presented with a manic episode twelve years back, for which he was hospitalized and treated with haloperidol. He later had one depressive and three manic episodes. Carbamazepine in a dose of 600mg was initiated ten years back during the second manic episode but the compliance was poor as the patient would consume alcohol. Haloperidol decanoate was added during the third manic episode two years back. It had to be discontinued after one year as patient had extrapyramidal side effects. Chlorpromazine was introduced in a dose of 100mg at 62
night. The patient was maintaining well for almost one year. Four months prior to this admission to the hospital patient received oral haloperidol 10mg/ day for a fortnight as he had an episode of hypomania. Mr. A.N. reported two months later with history of slowed movements and tremors of both upper extremities with worsening for ten days. On mental status examination he was found to be anxious but had no symptoms or signs of depression. On physical examination patient was found to have coarse rhythmic tremors of both upper extremities (more in the right extremity), lips and jaw, masked facies, bradykinesia, cogwheel rigidity, increased salivation and slurred speech. He was started on tablet clonazepam 2mg at night and carbamazepine and chlorpromazine were omitted and an adequate intake was maintained. On the third day of hospitalization oral promethazine (25mg) thrice daily was added. The dose of promethazine was stepped up to 125 mg a day in divided doses on day four. Clonazepam was continued at same dose of 2 mg at night. On day five, patient complained of difficulty in swallowing. On examination he was found to be hyperthermic (temperature 102F), had tachypnoea (respiratory rate 24/min.), tachycardia (pulse rate 104/min, regular), diaphoresis and lead pipe rigidity with fluctuation in blood pressure. Laboratory investigations showed leucocytosis (21,500/cc), elevated CPK (3000 IU/L), and moderately abnormal liver function tests. Promethazine was omitted and patient was transferred to the department of medicine where his signs and symptoms of neuroleptic malignant syndrome improved with bromocryptine 5mg three times a day, amoxycillin 500mg three times a day and supportive measures after ten days. At discharge consultation with a Neurologist was sought for parkinsonian features, he was diagnosed as having drug induced parkinsonism and started on tablet roprinerole 0.25 mg twice daily, selegeline Archives of Indian Psychiatry 8(2) October 2007
Pereira et al : Promethazine induced Neuroleptic Malignant Syndrome in a patient with Bipolar Affective Disorder 5 mg twice daily, clonazepam 2 mg at night, and carbamazepine 200 mg thrice a day. Patient came for follow up a week later. He was found to be euthymic and had minimal extrapyramidal side effects. Tablet clonazepam was tapered and patient has been maintaining well with carbamazepine, roprinerole, and selegiline. Discussion: Promethazine, a member of the phenothiazine class of neuroleptics, is commonly used as an anticholinergic agent. Neuroleptic malignant syndrome due to promethazine has been reported by Kish et al (1999)7. He was neither agitated nor was he dehydrated and he developed neuroleptic malignant syndrome after the dose of promethazine was stepped up. Being a male and having a bipolar illness were the risk factors for development of neuroleptic malignant syndrome in our patient. The development of neuroleptic malignant syndrome in our patient cautions us to use promethazine judiciously in patients with mood disorder having parkinsonian features. Probably stepping up the dose of promethazine needs to be done gradually in such patients. References: 1. Caroff S.N., Mann S.C. (1993) Neuroleptic malignant syndrome- A review. Medical Clinics of North America, 77, 185-202. Ebadi M., Pfeiffer R.F., Murrin L.C. (1990) Pathogenesis and treatment of neuroleptic malignant syndrome- a review. General pharmacology, 21, 36786. Heiman-Patterson P.D. (1993) Neuroleptic malignant syndrome and malignant hyperthermia, important issues for medical consultant (review). Medical Clinics of North America, 77, 477-92 Gurrea R.J. (1999) Sympathoadrenal hyperactivity and etiology of neuroleptic malignant syndrome. American Journal of Psychiatry, 157, 310-11. Velamoor V.R., Norman R.M.G., Caroff S.N., Mann S.C., Sullivan K.A. (1994) Progression of symptoms in neuroleptic malignant syndrome. Journal of Nervous and Mental Diseases, 182, 168-73. Adityanjee C.H.M. (1989) Neuroleptic malignant syndrome after neuroleptic discontinuation. Progress in Neuro-psychopharmacology and Biological Psychiatry, 19, 1323-34.7. Kisk M., Tack C. (1999) Neuroleptic malignant syndrome due to Promethazine. Southern Medical Journal, 92(10), 1017-18.
2.
3.
.4.
5.
6.
Sources of support: None
Conflict of Interest: None
Yvonne S. Pereira, Associate Professor Ashish Srivastava, Senior Resident Melvin CSilva Institute of Psychiatry and Human Behavior Bambolim, Goa- 403202. Correspondence: Dr. Yvonne S. Pereira House No. 2, Gomeco co-operative Housing Society, Bambolim, Goa 403202. e-mail: dryvonne@rediffmail.com

63
Quiz
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. was the first editor of Indian Journal of Psychiatry. The first General Hospital Psychiatry OPD Services in Mumbai was begun at Hospital The seal of American Psychiatric Association bears the picture of psychiatrist are Royal road to unconscious according to Freud. has authored a book, Indian Children on a psychiatrists playground has contributed to relation of bipolar disorder and temperament. Erik Erikson visited and gave lectures atInstitute, Ahmedabad. Ethologist Conrad Lorenz shared Nobel Prize withand. Infantile autism was first described by Myre Briggs Typology is based on psychological types described by . The first experiment of psychiatric services by PHC functionaries was carried out in block. is considered father of Indian Psychiatry. The book , Sane Society was authored by had accidental injury that led to knowledge regarding frontal lobe of brain. DSM1 was published in the year. Haryana, India in
Answers:
Contributed by : Dr. Khyati Mehtaliya MD, Consultant Psychiatrist, Sakhi Womens Mental Health and Child Guidance Clinic, 301, Ravish Complex , Maninagar Char Rasta, Ahmedabad 380008 e-mail: drkhyati@rediffmail.com 64
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
N.N.De J.J. Benjamin Rush Dreams Erna Hoch Hagop S. Akiskal B.M. Karl von Frisch and Niko Tinbergen Leo Kenner Carl Jung Raipur Rani Dr.Vidyasagar Eric Fromm Phineas Gage 1952


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2.7% 3.1% 15.3% 22.0% 22.3% 28.3%

10.7 10.6 10.5 10.4 10.3 10.2 10.1

10.6 10.5 10.4 10.3 10.5

112 suicides by female per day out of which 66 were housewives

Archives of Indian Psychiatry 8(2) October 2007

Jitendra Nanawala : Suicide : Western India Context

Archives of Indian Psychiatry 8(2) October 2007

Dr. L. P. Shah Oration

Child And Law

Archives of Indian Psychiatry 8(2) October 2007

P. C. Shastri : Child And Law

Assent Confidentiality Kidnapping Abduction Independence from lawful guardian

Employment For responsible post Witness

Archives of Indian Psychiatry 8(2) October 2007

Archives of Indian Psychiatry 8(2) October 2007 40053250

Archives of Indian Psychiatry 8(2) October 2007

To regard the child as an asset and a person with human rights

Archives of Indian Psychiatry 8(2) October 2007

Archives of Indian Psychiatry 8(2) October 2007

P. C. Shastri : Child And Law

Archives of Indian Psychiatry 8(2) October 2007

P. C. Shastri : Child And Law

Policy/Program National Policy for Children (NPC)

Areas Covered Comprehensive Health for all Children

Implementation with Reference to Children

Integated Child Development Services (ICDS)

Integrated Education for the Disabled Children (IEDC)

Archives of Indian Psychiatry 8(2) October 2007

National Mental Health Program

National Policy on Mental Handicap

Archives of Indian Psychiatry 8(2) October 2007

Archives of Indian Psychiatry 8(2) October 2007

Depression in Gynecology OPD

Archives of Indian Psychiatry 8(2) October 2007

13-70 27(7.54) 147(28.9) 191(37.7) 169(33.33) 393(77.5) 114(22.5)

Family Marital status

No of male child No of children<12

Archives of Indian Psychiatry 8(2) October 2007

Menstrual Problems Recent Changes H/o operation

H/O distress due to adverse pregnancy outcome

About weight and look

About Sexual desire and pleasure Conflicts with spouse*