GOVERNMENT OF INDIA

CENTRAL INSTITUTE OF PSYCHIATRY,

RANCHI

SEMINAR ON
EPIDEMIOLOGY. EPIDEMIOLOGICAL STUDIES IN INDIAN CONTEXT; SOCIO-
CULTURAL CORRELATES OF MENTAL ILLNESS

Chairperson: Dr. Preeti Gupta

Co-Chairperson: Ms. Sarah Hussain
Presenter: Ankita Raipure
Discussant: Snehaa

PRESENTER DISCUSSANT
● Introduction to Epidemiology ● Types of Epidemiological studies
● Historical context ● Socio-cultural correlates of mental illness
● Measures ● Indian Epidemiological studies

EPIDEMIOLOGY
INTRODUCTION TO EPIDEMIOLOGY
Definition
Epidemiology is defined as “the study of the distribution and determinants of health-related states or
events in specified populations, and the application of this study to the prevention and control of health
problems” (WHO). Psychiatric Epidemiology is a branch of psychiatry and public health that investigates
how mental health disorders are distributed in the population. Epidemiologists are concerned not only with
death, illness and disability, but also with more positive health states and, most importantly, with the means to
improve health. It focuses on following parameters:
• How many people are suffering from a given disorder at any point of time
• How a disease of interest is distributed in terms of several socio demographic variables like age, sex,
education, occupation, income and residence.
• What are the causes for given mental disorders in terms of social, biological, environmental,
psychological and cultural factors?
• The changing pattern of a given disease in a population
• The natural history of given illness in terms of relapse, remission or recovery
• The syndrome wise distribution
• The conceptual construction of diagnostics and classification through the development of cultural
specific and standardised instruments and approaches.
• The evaluation of possible intervention in terms of outcome and effect at individual and community
level

Scope
The focus of an epidemiological study is the population defined in geographical or other terms; for
example, a specific group of hospital patients or factory workers could be the unit of study. A common
population used in epidemiology is one selected from a specific area or country at a specific time. This forms
the base for defining subgroups with respect to sex, age group or ethnicity. The structures of populations vary
between geographical areas and time periods. Epidemiological analyses must take such variation into account.

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Uses
The most common applications of epidemiology in public health are as follows:
1. Collecting and analysing vital records (births and deaths) and disease records (morbidity)
2. Monitoring diseases or other community health problems.
3. Investigating outbreaks leading to control and prevention of epidemics and other community health
problems.
4. Identifying public health problems and measuring the extent of their distribution, frequency, or effect
on the public’s health.
5. Evaluating health programs.
6. Providing data necessary for health planning or decision making by health agency administrators or
health policy makers.

HISTORICAL CONTEXT
Origin
Epidemiology originates from Hippocrates’ observation more than 2000 years ago that environmental
factors influence the occurrence of disease. However, it was not until the nineteenth century that the
distribution of disease in specific human population groups was measured to any large extent. This work
marked not only the formal beginnings of epidemiology but also some of its most spectacular achievements.
Comparing rates of disease in subgroups of the human population became common practice in the late
nineteenth and early twentieth centuries. This approach was initially applied to the control of communicable
diseases, but proved to be a useful way of linking environmental conditions or agents to specific diseases. In
the second half of the twentieth century, these methods were applied to chronic noncommunicable diseases
such as heart disease and cancer, especially in middle and high-income countries.

Classical Epidemiology
In Great Britain medical registration of deaths had been introduced in 1801 and in 1838 William Farr
(1807-1883) introduced a national system of recording causes of death. Once the mechanism started to work
it provided a wealth of data which Farr himself analysed with great skill.
John Snow located the home of each person who died from cholera in London during 1848–49 and
1853–54, and noted an apparent association between the source of drinking water and the deaths. He
compared cholera deaths in districts with different water supplies and showed that both the number of deaths
and the rate of deaths were higher among people who supplied water by the Southwark company. On the
basis of his meticulous research, Snow constructed a theory about the communication of infectious diseases
and suggested that cholera was spread by contaminated water.

The new epidemiology

Individual studies on cancer, non-rheumatic cardiovascular diseases, and psychiatric diseases, can be
traced well back in time, but one can take as a convenient turning point for the rise of new epidemiology the
period around the Second World War. A major stream in the development of the new epidemiology is what
could be labelled as the ‘tobacco and health story’. Initial observations were either of a statistical nature or of a
clinical one. Among the first one can mention is a short and remarkable paper by Pearl (Pearl, 1938) using
insurance data showing that the expectation of life for smokers was substantially reduced in respect to the non-
smokers. This phase of the development of epidemiology received new input from the two-way exchange
between epidemiology and clinical medicine which has been a constant feature in the history of the subject.

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MEASURES IN EPIDEMIOLOGY
Measures of Disease Frequency
A measure of central location provides a single value that summarizes an entire distribution of data. In
contrast, a frequency measure characterizes only part of the distribution. Frequency measures compare one
part of the distribution to another part of the distribution, or to the entire distribution. Common frequency
measures are- ratios, proportions and rates.
a. Rates: A rate is a measure of the frequency with which an event occurs in a defined population in a
defined time (e.g., number of deaths per hundred thousand Indians in one year). It has time
dimension, whereas a proportion (e.g., number of Indians with cancer divided by total population)
does not. In epidemiology, a rate is a measure of frequency with which an event occurs in a defined
population over a specified period of time.
b. Proportion: A proportion is the comparison of a part to the whole. It is a type of ratio in which the
numerator is included in the denominator. Proportion might be used to describe what fraction of
clinic patients tested positive for HIV, or what percentage of the population is younger than 25 years
of age. A proportion may be expressed as a decimal, a fraction, or a percentage.

Method for calculating a proportion

Number of persons or events with a particular characteristic
× 10 n
Total number of persons or events, of which the numerator is a subset

c. Ratio: A ratio is the relative magnitude of two quantities or a comparison of any two values. It is
calculated by dividing one interval- or ratio-scale variable by the other. The numerator and
denominator need not be related. Therefore, one could compare apples with oranges or apples with
number of physician visits.
The important difference between a rate and a ratio is that for a rate, the numerator is included in the
denominator (e.g., number of new cases of a disease divided by the total population). In a ratio, the
numerator and denominator are usually separate and distinct quantities, neither being included in the other
(e.g., the ratio of males to females in the class).

Method for calculating a ratio

Number or rate of events, items, persons,
etc. in one group

Number or rate of events, items, persons,

etc. in another group

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Morbidity Frequency Measures
Morbidity has been defined as any departure, subjective or objective, from a state of physiological or
psychological well-being. In practice, morbidity encompasses disease, injury, and disability. In addition, the
term refers to the number of persons who are ill, it can also be used to describe the periods of illness that
these persons experienced, or the duration of these illnesses.
Measures of morbidity frequency characterize the number of persons in a population who become ill
(incidence) or are ill at a given time (prevalence). Commonly used measures are
a. Incidence proportion or risk: Incidence proportion is the proportion of an initially disease-free
population that develops disease, becomes injured, or dies during a specified (usually limited) period
of time. Synonyms include attack rate, risk, probability of getting disease, and cumulative incidence.
Incidence proportion is a proportion because the persons in the numerator, those who develop
disease, are all included in the denominator (the entire population).

Method for calculating incidence proportion (risk)

Number of new cases of disease or injury during specified period /
Size of population at start of period

b. Incidence rate or person-time rate: Incidence rate or person-time rate is a measure of incidence
that incorporates time directly into the denominator. A person-time rate is generally calculated from a
long-term cohort follow-up study, wherein enrolees are followed over time and the occurrence of new
cases of disease is documented. Similar to the incidence proportion, the numerator of the incidence
rate is the number of new cases identified during the period of observation. However, the
denominator differs. The denominator is the sum of the time each person was observed, totalled for
all persons. This denominator represents the total time the population was at risk of and being
watched for disease. Thus, the incidence rate is the ratio of the number of cases to the total time the
population is at risk of disease.

Method for calculating incidence rate-

Number of new cases of disease or injury during specified period /
Time each person was observed, totalled for all persons

c. Prevalence: Prevalence, sometimes referred to as prevalence rate, is the proportion of persons in a

population who have a particular disease or attribute at a specified point in time or over a specified
period of time. Prevalence differs from incidence in that prevalence includes all cases, both new and
pre-existing, in the population at the specified time, whereas incidence is limited to new cases only.
Point prevalence refers to the prevalence measured at a particular point in time. It is the proportion
of persons with a particular disease or attribute on a particular date.
Period prevalence refers to prevalence measured over an interval of time. It is the proportion of
persons with a particular disease or attribute at any time during the interval.

Method for calculating prevalence of disease

All new and pre-existing cases during a given time period
× 10 n
Population during the same time period

Method for calculating prevalence of an attribute

Persons having a particular attribute during a given time period
× 10 n
Population during the same time period

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Mortality Frequency Measures
A mortality rate is a measure of the frequency of occurrence of death in a defined population during a
specified interval. Morbidity and mortality measures are often the same mathematically; it's just a matter of
what you choose to measure, illness or death.
The formula for the mortality of a defined population, over a specified period of time,
Deaths occurring during a given time period
× 10 n
Size of the population among which the deaths occurred

Frequently Used Measures of Mortality

Measure Numerator Denominator
Crude death rate Total number of deaths during a given time Mid-interval population
interval
Cause-specific death Number of deaths assigned to a specific Mid-interval population
rate cause during a given time interval
Proportionate Number of deaths assigned to a specific Total number of deaths from all causes
mortality cause during a given time interval during the same time interval
Death-to-case ratio Number of deaths assigned to a specific Number of new cases of same disease
cause during a given time interval reported during the same time interval
Neonatal mortality rate Number of deaths among children Number of live births during the same
< 28 days of age during a given time interval time interval
Post neonatal mortality Number of deaths among children 28–364 Number of live births during the same
rate days of age during a given time interval time interval
Infant mortality rate Number of deaths among children Number of live births during the same
< 1 year of age during a given time interval time interval
Maternal mortality rate Number of deaths assigned to pregnancy- Number of live births during the same
related causes during a given time interval time interval

Measures of Association
The key to epidemiologic analysis is comparison. Occasionally one might observe an incidence rate
among a population that seems high and wonder whether it is actually higher than what should be expected
based on, say, the incidence rates in other communities.
A measure of association quantifies the relationship between exposure and disease among the two
groups. Exposure is used loosely to mean not only exposure to foods, mosquitoes, a partner with a sexually
transmissible disease, or a toxic waste dump, but also inherent characteristics of persons (for example, age, race,
sex), biologic characteristics (immune status), acquired characteristics (marital status), activities (occupation,
leisure activities), or conditions under which they live (socioeconomic status or access to medical care).
Examples of measures of association include risk ratio (relative risk), rate ratio, odds ratio, and
proportionate mortality ratio
a. Risk ratio: A risk ratio (RR), also called relative risk, compares the risk of a health event (disease,
injury, risk factor, or death) among one group with the risk among another group. It does so by
dividing the risk (incidence proportion, attack rate) in group 1 by the risk (incidence proportion,
attack rate) in group 2. The two groups are typically differentiated by such demographic factors as sex
(e.g., males versus females) or by exposure to a suspected risk factor (e.g., did or did not eat potato
salad). Often, the group of primary interest is labelled the exposed group, and the comparison group
is labelled the unexposed group.

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Method for Calculating risk ratio
The formula for risk ratio (RR) is:
Risk of disease (incidence proportion, attack rate) in group of primary interest
Risk of disease (incidence proportion, attack rate) in comparison group

a. Rate ratio: A rate ratio compares the incidence rates, person-time rates, or mortality rates of two
groups. As with the risk ratio, the two groups are typically differentiated by demographic factors or by
exposure to a suspected causative agent. The rate for the group of primary interest is divided by the
rate for the comparison group.
Rate ratio =
Rate for group of primary interest /
Rate for comparison group

b. Odds ratio: An odds ratio (OR) is a measure of association between an exposure and an outcome.
The OR represents the odds that an outcome will occur given a particular exposure, compared to the
odds of the outcome occurring in the absence of that exposure. Odds ratios are most commonly used
in case-control studies; however, they can also be used in cross-sectional and cohort study designs as
well (with some modifications and/or assumptions).
OR = Odds of disease in exposed /
Odds of disease in the non-exposed

TYPES OF EPIDEMIOLOGICAL STUDIES

Observational epidemiology
Observational studies allow nature to take its course: the investigator measures but does not
intervene. They include studies that can be called descriptive or analytical:
● A descriptive study is limited to a description of the occurrence of a disease in a population and is
often the first step in an epidemiological investigation.
● An analytical study goes further by analysing relationships between health status and other variables.

Descriptive studies:
A simple description of the health status of a community, based on routinely available data or on data
obtained in special surveys, is often the first step in an epidemiological investigation. They are usually based
on mortality statistics and may examine patterns of death by age, sex or ethnicity during specified time periods
or in various countries.

Analytical studies
a. Case-control studies: Case-control studies provide a relatively simple way to investigate causes of
diseases, especially rare diseases. They include people with a disease (or other outcome variable) of
interest and a suitable control (comparison or reference) group of people unaffected by the disease or
outcome variable. The study compares the occurrence of the possible cause in cases and in controls.
The investigators collect data on disease occurrence at one point in time and exposures at a previous
point in time.
b. Cohort studies: Cohort studies, also called follow-up or incidence studies, begin with a group of
people who are free of disease, and who are classified into subgroups according to exposure to a
potential cause of disease or outcome. Variables of interest are specified and measured and the whole
cohort is followed up to see how the subsequent development of new cases of the disease (or other
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 outcome) differs between the groups with and without exposure. Because the data on exposure and
disease refer to different points in time, cohort studies are longitudinal, like case control studies.

Prospective studies
A prospective cohort study is a cohort study that follows over time a group of similar individuals
(cohorts) who differ with respect to certain factors under study, to determine how these factors affect rates of
a certain outcome.The distinguishing feature of a prospective cohort study is that at the time that the
investigators begin enrolling subjects and collecting baseline exposure information, none of the subjects have
developed any of the outcomes of interest. After baseline information is collected, subjects in a prospective
cohort study are then followed “longitudinally”.

Advantages:
 Help determine risk factors for being infected with a new disease
 The collection of results is at regular time intervals, so recall error is minimized

Retrospective studies
It is a medical research study in which the medical records of groups of individuals who are alike in
many ways but differ by a certain characteristic are compared for a particular outcome. The time to complete
a retrospective study is only as long as it takes to collect and interpret the data. Retrospective studies examine
possible risk and protection variables in relation to a result that is already established at the start of the study.

Advantages:
 They are conducted on a smaller scale
 They typically require less time to complete
 They are better for analysing multiple outcomes
 They can potentially address rare diseases.

PSYCHIATRIC EPIDEMIOLOGY IN INDIA

• Dr. Govinda Swamy was the first person to consider psychiatric epidemiology in India but it failed
due to methodological errors.(1957)
• The first major survey on psychiatric problem in India was undertaken by K.C. Dube in Agra in 1961.
• 1960 – 1980 – series of descriptive population based studies in last four decades have been of
psychiatric morbidity in small to medium population
• A meta-analysis of 13 epidemiological studies in India in 1996 concluded a prevalence rate of 58.2 per
1000 population among the various problems , organic psychosis -0.4/1000 ; Schizophrenia –
2.7/1000 ; Affective disorder – 12.3/1000 ; Mental Retardation – 6.9 /1000 , Neurotic disorder – 20/
1000, and alcohol related disorder- 6.9/1000 (Reddy and chandrashekhar 1998)
• Mental and behavioural disorders account for about 12 percent of the global burden of diseases
(WHO).
• In 2000, review of epidemiological studies estimated that the prevalence of mental disorders in India
was 70.5 per 1000 in rural and 73 per 1000 in the urban population. (ganguli 2000)
• A study conducted in Pune in 2012 reported the overall life time prevalence of mental disorders to be
nearly 5 percent.
• In 2010, a study conducted in NIMHANS, Bangalore reported that the burden of mental and
behavioural disorders ranged from 9.5 to 102 per 1000 population.

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 • Another study among elderly done in South India in 2009 found the prevalence of depression to be
12.7 percent.
• The prevalence of dementia was found to be 33.6 per 1000 by a study done in urban population of
Kerala in 2005. Alzheimer’s disease was the most common cause (54%) followed by vascular
dementia (39%).
• In 1999, a study stated that the prevalence of mental disorders in child and adolescent population was
9.4 percent.
• Similarly, another study from Bangalore in 2005 documented that the prevalence of mental disorders
among 0-3 years old children was 13.8 percent. The prevalence rate in the 4-16 years old children was
12.0 percent

SCHIZOPHRENIA
 It is estimated to affect 1% of the general population but it occurs in 10% of people who have a first
degree relative with the disorders.
 Schizophrenia occurs in all populations with a prevalence in the range of 1.4 to 4.6 per 1000 and
incidence rates in the range of 0.16-0.42 per 1000 population
 International pilot study of Schizophrenia (IPSS) - IPSS was an international multicentred study which
was initiated in 1965 (Malhotra, 1997) where a total of nine field research centres were chosen all over
the world, the centre in India was situated in Agra. The Indian sample consist of 101 schizophrenia, 8
affective and 11 neurotic patients. A total of 1202 patients were recruited at all the 9 centres and
follow up at 1 year, 2 years and 5 years. The major conclusions of the study were:
● There was a great variability in the course and outcome of schizophrenia.
● Centres in developing countries had a better course and outcome than developed countries.
● Predictors of poor outcome were insidious onset, long duration of episode, social isolation, past
history of psychiatric treatment and being divorced separated or widowed.
However IPSS had certain limitations, it recruited patients from consecutive admissions to
psychiatric centres and it did not address the issue of incidence of schizophrenia.
Determinants of outcomes of severe Mental Disorder (Sekar and Murthy, 1999)-The aims of
DOSMED was to produce estimates of incidence of schizophrenia in different cultures and provide definite
evidence about the course and outcome of schizophrenia in different part of the world (Malhotra, 1997).
Twelve centres in ten countries participated in this study, the centre in India were at Agra and Chandigarh.

The findings of the study are as follow:

● Remitting course and favourable outcome were significantly more common amongst patients in
developing countries.
● Predictors of poor outcome were later age of onset of illness, female gender, married at initial
evaluation, hebephrenic and residual subtypes of schizophrenia.

 Study of factors affecting the course and outcome of schizophrenia (SOFACOS) (ICMR –1988): The
study was conducted by ICMR at Lucknow, Madras and Vellore with sample size of 386 patients. The
aim was:
● To identify socio cultural and clinical variables of schizophrenia which are associated with and might
be etiologically related to the course and outcome
● To confirm the results of IPSS regarding course and outcome of schizophrenia in developing

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 countries.
● To see if the course and outcome of schizophrenia is different among three centres which had
different socio-cultural backgrounds.

It was reported that

● The course, outcome and clinical manifestations of schizophrenia were similar in all three centres.
● Most of the symptoms subsided after 2 years and remained the same after 5 years.
● The follow up rate was about 84% at the end of 2 years and 75% after 5 years.
● Factors significantly related to the course and outcome after 5 years were- drug compliance, absence
of dangerous behaviour, rise in socio economic level, low level of education, short duration of illness,
younger age of onset, absence of economic difficulties, absence of delusions of persecution and
presence of agitation.
 Study of functional psychoses in an urban community” (SOFPUC) - A more recent study has been
conducted in Chennai (Padmavati et al, 1988) with prevalence rate of estimated as 2.49/1000 with
higher rate of illness has been estimated in urban slums as compared to the rest of the urban
population.(ICMR 1990).
 A Bangalore study conducted on a schizophrenia population of 32,645 and found the prevalence rate
to be 3.09/ 1000(ICMR 1990).
Incidence Rate –The estimation of incidence rate were mainly from West Bengal (Nandi et al, 1975),
Chandigarh (Varma, 1989) and Chennai (Raj Kumar et al, 1993). The estimated incidence rate from west
Bengal was 0.93/1000 with similar incidence rate in both male and female however not much inference can
be drawn from this study as only new case of schizophrenia was seen during the study period. The annual
incidence rate for schizophrenia in Chandigarh under WHO collaborative study of determinants of outcomes
of severe Mental Disorders (DOSMED) (JablenSsky et al, 1992) were 0.38/1000 with higher incidence in
rural female ( 0.47/1000) while lowest in the urban females (0.37/1000). In Chennai the incidence rate was
0.35/1000.
❖ A study carried by SCARF and the Department of Psychiatry, Madras Medical College and a
population of over 100,000 was screened.
• Prevalence rate of schizophrenia was 3.87/1000
• The incidence rate in the study was 0.35 / 1000.
❖ SCARF has successfully conducted a 20-year follow-up study on first episode schizophrenia patients
and found that:
• 8 % had achieved complete remission
• 39 % had relapses with complete remission between episodes
• 44 % had relapses with partial remission between episodes
• 8 % had a course of illness that was continuous in nature
• Mortality rates were quite high with the average age of death being 34.2 years, much below the
average Indian lifespan of 60.5 years in 2002. Suicides accounted for 7 out of the 16 deaths.
• Another SCARF-study published in 2006 described the symptoms seen in 143 never treated schizo-
phrenia patients.
The average duration of untreated illness was 10.7 years with the mean age of onset being 36.2 years.
Nearly half the sample had delusions, suspiciousness/persecution, hallucinatory behaviour and conceptual
disorganisation. Another retrospective epidemiological study was conducted on 54 schizophrenic patients
visiting Santvan Hospital Nadiad, Gujarat (Galani et al, 2013).

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 Out of the 54 patients, 26 (48.2 %) were males and 28 (51.9 %) were females.
The maximum number of cases occurred in males between the ages of 15 and 20 years and in
females between the ages of 20 and 25 years
Under a WHO collaborative study, the Chandigarh centre monitored two geographically defined
populations over a 2-year period. 268 first-onset potentially schizophrenic cases were actively identified. Of
these, 232 cases could be assessed in detail.
The annual incidence rates obtained were 4.4 and 3.8 per 10,000 for rural and urban areas,
respectively.

BIPOLAR DISORDER
In a study conducted by Chopra et al., (2006) on the course of bipolar disorder in rural India, 34
patients diagnosed with bipolar disorder were followed longitudinally.
• Seven patients (26%) had an onset with an episode of depression or a mixed/cycling episode
• Patients without rapid cycling had a mean of 4.4 and a median of 3 major mood episodes resulting in
a mean of 0.22 episodes/year.
• 5 patients had experienced only a single episode of mania during the follow-up period
• Eighteen patients (67%) had an illness-course characterized by many more manic than depressive
episodes
• Seven patients (26%) also meet criteria for alcohol dependence
A study of socio-demographic profile, phenomenology, course and outcome of bipolar disorder in
Indian population was conducted by Ramdurg and Kumar (2013).This study was carried out in a private
sector hospital attached to a Medical College in Northern part of Karnataka, India. 100 patients were
recruited for the study. Recurrent mania was a commonly observed phenomenon and duration of suffering in
both phases was nearly 4 months.
The NMHS (National Mental Health Survey) pioneered by R Srinivas Murthy 2016 was undertaken in
12 states across six regions of India (North [Punjab and Uttar Pradesh]; South [Tamil Nadu and Kerala]; East
[Jharkhand and West Bengal]; West [Rajasthan and Gujarat]; Central [Madhya Pradesh and Chhattisgarh]; and
North-East [Assam and Manipur]). In each state, the dedicated team of investigators included mental health
and public health professionals. The overall weighted prevalence for any mental morbidity was 13.7% lifetime
and 10.6% current mental morbidity out of which Bipolar Affective Disorder was reported to be 70.4% with
a female predominance observed for depressive disorders (both current [female: 3.0%; male: 2.4%] and
lifetime).

DEPRESSION
• Depression is estimated to effect 340 million people globally
• Reddy and Chandrasekhar (1998) carried out a meta-analysis, which included 13 studies on
epidemiology of psychiatric disorders which include 33572 subjects from the community and
reported prevalence of depression to be 7.9 to 8.9 per thousand population and the prevalence rates
were nearly twice in the urban areas.
• The findings with regard to prevalence in urban population are in line with the findings of a survey
done on the entire adult population of an industrial township, which showed that the prevalence rate
for depression to be 19.4 per thousand (Sethi and Prakash, 1979).
• In another recent study, Nandi et al., 2000, compared the prevalence of depression in the same
catchment area after a period of 20 years (first in 1972 and then in 1992) and reported that the

10
 prevalence of depression increased from 49.93 cases per 1000 population to 73.97 cases per 1000
population.
• Studies done in primary care clinics/centre have estimated a prevalence rate of 21-40.45% (Kishore
et al., 1996; Nambi et al., 2002).
• Studies on the elderly population, either in the community, inpatient, outpatient and old age homes
have shown that depression is the commonest mental illness in elderly subjects (Nandi et al., 1997;
Guha et al., 2005).
• Nandi et al., 1997, studied psychiatric morbidity of the elderly population of a rural community in
West Bengal. In a sample of 183 subjects (male 85, female 98) they found 60% of the population to
be mentally ill with higher morbidity in women compared to men (77.6% and 42.4% respectively).
• There was significantly more morbidity in population in the age group 70-74 and 80+ as compared to
normal population. The total mental morbidity rate was as high as 612/1000 population.
• Women had a higher rate of depression-704/1000 population.
• Clinic-based studies have reported a prevalence rate of 1.2 to 9.2% for the affective disorders,
amongst which unipolar depression was the commonest category in most of the studies (Malhotra &
Chakrabarti, 1992; Choudhary et al., 1995).
• In a recent study evaluating the trend of various diagnoses in clinic population, Malhotra et
al.,(2007) reported increase in prevalence of affective disorders from 2% to 13.49% in children (0-14
years) attending the psychiatric outpatient clinics .
SUICIDE
• Data on suicide in India are available from the National Crime Records Bureau (NCRB; Ministry of
Home Affairs)
• The suicide rates in India rose from 6.3 per 100,000 in 1978 to 8.9 per 100,000 in 1990, an increase of
41.3% during the decade from 1980 to 1990.
• More recent data, however, reveal a different picture. The rate of suicide showed a declining trend
from1999 to 2002 and a mixed trend during 2003-2006, followed by an increasing trend from 2006 to
2010.
• During 2009, the rate was 10.9 per 100,000 population. This represented a 1.7% increase in suicides
since 2008.
• In the most recent NCRB report the rate in 2010 rose to 11.4 per 100,000 population; an increase of
5.9% in the number of suicides.
• Suicide is a leading cause of death among young people in India (Aaron et al., 2004).
• In a study which evaluated the cause of death among those aged 10-19 years, in a rural population of
108,000 in south India, suicide accounted for about a quarter of all deaths in males and between 50%
and 75% of all deaths in females aged 10-19 years (Aaron et al., 2004).
• The average suicide rate for girls was 148 per 100,000, and for boys, 58 per 100,000 (Aaron et al.,
2004).
• In 2009, 70.4% of all suicide victims in India were married and 21.9% were unmarried.
• Divorcees and individuals who were separated accounted for about 3.4%, while widows and widowers
comprised 4.3% of the total suicide victims.
• In individual studies, some show higher attempted suicides among unmarried persons while others
show a higher rate among those who are married.
• Among attempters, men were more likely to be single and women, married.

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 • In India, during 2009 consumption of a poison (33.6%), hanging (31.5%), self-immolation (9.2%),
and drowning (6.1%) were the commonest modes of suicide. Jumping from buildings accounted for
1.5%. This pattern is recapitulated in the NCRB 2010 report.

ANXIETY DISORDER
 A meta-analysis of 13 psychiatric epidemiological studies done by Reddy and Chandrashekhara (1998),
with a total sample size of 33,572 yielded an estimated prevalence rate of 20.7% of all neurotic
disorder.
 The weighted prevalence rates of different anxiety disorders were 4.2% (Phobia), 5.8% (GAD), 3.1%
(Obsession) and 4.5% (Hysteria)
This meta-analysis also reported that prevalence rates of all neurotic disorders except hysteria (5.0%
vs. 3.4%) were significantly higher (35.7% vs. 13.9%) in urban communities than rural, and all neurotic
disorders were significantly high among females (32.2% vs. 9.7%).
• Ganguli (2000) analysed 15 epidemiological studies on psychiatric morbidity in India.
• The prevalence rate (in per thousands) of anxiety neurosis was reported to be 16.5 with a rural urban
ratio of 100:106 and that of hysteria was 3.3 with a rural urban ratio of 100:44.
• Madhav (2001) in an analysis of 10 Indian studies on psychiatric morbidity, concluded that prevalence
rates for anxiety neurosis and hysteria were 18.5 and 4.1 per 1000 population respectively.
• One population-based study on geriatric population was reported by Tiwari and Srivastava (1998)
▪ In this study nearly 9% of the subjects were diagnosed with ICD-9 (World Health
Organization) anxiety neurosis
• Nagaraja (1996) observed childhood neuroses in 9.7% of out-patient population and 9.3% of
inpatients over a period of seven years in Hyderabad with a male to female ratio of 1:2.
• Manchanda et al., (1969) found neurotic behaviour in 27.3% children admitted for physical ailments.
• In children seen at the Child Guidance Clinic of the Madras Government General Hospital during the
year 1964-1966, Raju et al.,(1969) found that 22 of the 592 children were neurotics and 16 were
hysterical.
In an urban survey of 109 families for psychiatric morbidity in children below 12 years, Lal and Sethi
(1977) reported emotional disturbance in 55% families and 35.4% of the total children surveyed. Neurotic
disorders were found in 11.0% of the total sample.
 In an another epidemiological study conducted by Manchanda and Manchanda (1978), a total of 19
children (up to 12 years) from the Paediatric inpatient and Child Guidance Clinic (CGC) were
diagnosed to be suffering from a neurotic disorder during a period of 11 months.
• Incidence of neuroses was 1.1% among paediatric inpatients and 8.2% in CGC.
• The incidence was higher in the females.
• 73.5% of children were in the age range of 10-12 years. None of them were below six years.
• Hysteria was the commonest diagnostic group (71.4%) in the present study.
• Other disorders in order of frequency were anxiety (16.3%) depression (6.1%) and phobia
(4.1%).
Obsessive compulsive neurosis was observed in one case only.
 In another epidemiological study of possession syndrome (Venkataramaiah et al., 1981) conducted in
West Karnataka reported high prevalence rates of 51% in age group <15 years and 28% in age group
15-25 years (n = 718). One year period prevalence was found to be 3.7%.

12
Personality Disorder
• The prevalence of personality disorders was assessed in seven studies and the rate varied from 0
to 2.8%.
• Personality disorder diagnosis was significantly associated with the male gender.
• Early studies (that did not employ diagnostic instruments or operationalized criteria) on clinical
samples from India reported prevalence rates of 0.3-1.6%.
• The rates were higher in special populations such as university students (19.1%); criminals (7.3-
33.3%); patients with substance use disorders (20-55%); and patients who attempted suicide (47.8-
62.2%).
• In the International Pilot Study of Personality Disorders (IPSPD), the following personality
disorders were frequently diagnosed in the clinical sample at Bangalore: Schizotypal (19.1%) and
borderline (14.7%) according to the DSM-III-R system; and emotionally unstable (8.6%)
according to the ICD-I0 system.
• Banerjee and Mitra compared 50 teenage girl outpatients with academic difficulties with normal
controls and found that;
▪ about 30% of the index group had emotionally unstable personality disorder (impulsive
type)
▪ 6% had dependent personality disorder
▪ 6% other personality disorders
Studies relating to self-harm
• The rate of personality disorders in subjects who have demonstrated acts of self-harm have varied
from 7% to 64%.
• Nath et al., used the International Personality Disorder Examination (IPDE) to assess outpatients and
inpatients, who presented with a history of self-harm at any point in their life, in two age groups (15-
24 years and 45-74 years)
▪ 64% of the older group and 58.5% of the young subjects were reported to have a personality
disorder
▪ In both the groups the most common personality disorders were anankastic and emotionally
unstable personality
▪ In the young group emotionally unstable personality and anankastic personlity were found to
be in 28.6 % and 11.7% of subject respectively, while in the older group emotionally unstable
personality and ananakastic personality was found in 13.8% and 34.5% of subjects
respectively.
• A study by Latha et al., yielded a (similar) prevalence rate of 12% for personality disorders in those
attempting self-harm.
• A study that only assessed the presence of borderline personality disorder with a semi-structured
interview, in patients who had made a suicide attempt, yielded a much higher rate of 18.3% for this
single diagnosis.
Substance use disorders (SUDs) – Over a three-year period, past year incidence of alcohol abuse and
alcohol dependence was 1.0% and 1.7% respectively, further, among individuals with DSM-IV dependence at
Wave 1, 30.1% of cases persisted at full symptoms level at Wave 2. Among respondents with alcohol
dependence at Wave 1, 5.4%. Reported pas year abstinence (abstinent recovery), and 5.5% drank but did not
endorese any DSM-IV alcohol dependence or abuse symptoms in past year (non-abstinent recovery), at Wave

13
2. Help-seeking, including participation in 12-step programs and formal treatment increased the likelihood of
recovery from alcohol dependence with an onset at least 12 months prior to the interview.
In the NESARC sample, 30.9% of respondents with a SUD at Wave 1 recognized symptoms and criteria for
an SUD at Wave 2. Of these persistent cases, 85.7% of persons met criteria for the same substance specific
disorder at both waves, while 14.3% of respondents did not. The incidence of illicit drug use among Wave 1
& 2 was low among non-users. At Wave 2, 2.1% of non-users at baseline-initiated use, and 2.5% of non-users
at baseline-initiated problematic use. Among asymptomatic users at baseline, 19.1% became problematic
users. Prevalence estimates for substance use disorder were uppermost for cannabis, cocaine and heroin
(Grant, 2016).
Large number of studies in student populations, including medical students from 1963 to 1984 have varied
greatly in their definition of drug use/abuse which studies reveals that the prevalence rates of use in student
varied from 5.0- 56.2% the rates being higher in medical students and tobacco, alcohol, painkillers,
tranquilizers and cannabis v is being the common only used drugs (Channabasavanna, 1989).
Substance use disorder including alcohol use disorder, moderate to severe use of tobacco and use of other
drugs (illicit and prescription drugs) was prevalent in 22.4 % of the population above 18 years in all the in 12
surveyed states. The prevalence of tobacco use disorder (moderate and high dependence) and alcohol use
disorder (dependence and harmful use / alcohol abuse) was 20.9% and 4.6%, respectively. The prevalence of
alcohol use disorders in males was 9% as against 0.5% in females. The survey also revealed that 0.6% of the
18+ population were recognised with illicit substance use disorders (dependence + abuse) which included
cannabis products, opioid drugs, stimulant drugs, inhalant substances and prescription drugs. Among adult
males this was 1.1% (NMHS, 2016).

Major contribution from CIP:

● As part of a world mental health survey covering the total population of Ranchi Municipal
Corporation, a door to door survey was undertaken. Apart from estimation of the prevalence of
mental disorders in Ranchi, this study tried to assess the health care utilization as well as disability and
burden caused by mental illness (Nizamie and Akhtar, 2006a).
● In another ongoing research project on epilepsy, a door to door survey has been supplemented by
involving private practioners, indigenous practioners and faith healers. Besides giving a clear picture
of extent of the problem and its burden, this project is trying to develop a unique services delivery
model that will diminish stigma, spread awareness, improve referral as well as treat the patients at
their doorsteps which will have important implication in future policy development (Nizamie and
Akhtar, 2006b).
● CIP is coordinating centres of National Household survey on Drug and Alcohol abuse. In this
multicentre study Jharkhand, Orissa and west Bengal was the area of study under CIP. All the
members of the Household were interviewed through a structured proforma to know the substance
specific prevalence (Khess, 2002).
● Studies like 1. Prevalence of conduct disorder in school children of Kanke (Sarkhel and Sinha, 2005),
2. Prevalence of alcohol use among college students and relationship between age of first intoxication
(Sengupta and Khess, 2005).

14
SOCIO CULTURAL CORRELATES IN MENTAL ILLNESS:
The phenomenology of major mental disorders (schizophrenia and affective disorders) is recognized
in all parts of the world. It was previously assumed that culture merely plays a patho-plastic effect on the
strong central biological pathogenesis of these disorders (Yap, P. M. 1974). However, current understanding
is that culture has multiple roles to play in the expressions of psychopathology. These are as follows: (Tseng,
W. S., & Strelzer, J., 2013).
1. Pathogenic effects - Culture is a direct causative factor in forming or generating illness
2. Patho-selective effects - Tendency to select culturally influenced reaction patterns that result in
psychopathology
3. Patho-plastic effect - Culture contributes to modeling or shaping of symptoms
4. Patho-elaborating effects - Behavioral reactions become exaggerated through cultural reinforcements
5. Patho-facilitative effects - Cultural factors contribute to frequent occurrence
6. Patho-reactive effects - Culture influences perception and reaction.
Cultural Influence on phenomenology

Schizophrenia

Subtypes

The first systematic examination of schizophrenia subtypes ( Murphy HB 1982) found that catatonic
subtype was rare in the West, hebephrenic subtype was common in Japan, and simple subtype was
common in Asia. The International Pilot Study of Schizophrenia (IPSS) sheds more light on this
issue.( WHO. Report of the International Pilot Study of Schizophrenia. 1973). Paranoid schizophrenia
was the commonest subtype (40%). The hebephrenic subtype (11%) was more prevalent in Cali and
Taipei, whereas the catatonic subtype (11%) was more in developing countries (Agra, Cali, and Ibadan).

Another transcultural study, International Study on Psychotic Symptoms (ISPS) found the catatonic
subtypes to be equally prevalent in all sites; this may be due to the use of DSM-IV criteria for examining
catatonic schizophrenia (Stompeetal., 2005) .

Symptoms

Delusions: Themes of delusions have been found to be related to patients' social background, cultural
beliefs, and expectations. (Kala AK, Wig NN. 1982) Religious delusions are common in Christian
societies, whereas these are rarer in Hindu, Muslim, or Buddhist societies. (Kala AK, Wig NN. 1982,
Tateyama, etal 1998).

Magical religious delusions have also been found to be greater in rural societies, especially in women
>30 years of age. Low rates of religious delusions, grandiose delusions, and delusions of guilt were
found in Pakistan, the only pure Islamic country in the study. (Stompe etal.,2006).

In contrast, religious grandiosity was more common in African countries. The cultural content of the
delusions recurs in future episodes of psychosis. (Sinha, V. K., & Chaturvedi, S. K1990)

Hallucinations: The first large-scale cross-cultural evaluation of hallucinations Murphy et al.,

1963] found that visual hallucinations were more common in Africa.

The ISPS showed that auditory hallucinations were commonest in all cultures and that visual
hallucinations were the commonest in Africa and the rarest in Pakistan. The cultural content of
hallucinations also recurs in future psychotic-episodes (Chaturvedi.SK, SinhaV1990)

Other symptoms: Negative symptoms and neuropsychological deficits are common in most cultures.
There are differences in the frequency of types of negative symptoms between patients in India and the
United States (Chaturvedi SK. 1986).
Symptoms in schizophrenia such as not eating, not sleeping, and negative symptoms were reported to be
more distressing in Indian patients, compared to aggression and positive symptoms among those from
UK (GopinathPS,ChaturvediSK,1992).

15
 Reasons for cultural differences in psychopathology: Cross-cultural differences in language and thought
result in cross-cultural differences in symptoms and subtypes (Varma VK 1982)

Affective disorders

Culture greatly influences the way in which depressive symptoms are expressed.
In the WHO collaborative study on standardized assessment of depressive disorder,
Sartorius, N. (1983).583 patients in five centres (Basel, Montreal, Tehran, Nagasaki, and Tokyo) were
assessed for core depressive symptoms. Most of them had in common features of sadness, anhedonia, lack
of interest and energy, impaired concentration, and ideas of worthlessness. Feelings of guilt and suicidal
ideations were least common in Tehran.

a. Indian studies have also found guilt to be less common among Indian patients than those in the
West; ( Venkoba Rao A. Depression 1966) in addition, they reported guilt of an impersonal nature:
The present suffering is attributed to possible bad deeds of previous life (consequence of "Karma")
rather than due to self-failure as in the West. Ananth et al.,1993 ).Studies in India have reported
physical symptoms to be common presenting symptoms in depression (Gada M,1971)
/ CONCLUSION
Considering the facts of systematic underreporting, collecting data from single informant, use of low sensitivity
screening instruments, poor sampling methods, assessing only priority mental disorders and changing health
scenario indicates that the prevalence of mental disorders as reported in Indian epidemiological surveys can be
considered lower estimates rather than accurate reflections of the true prevalence in the population. This should be
kept in mind especially for policy making and for mental health care planning. Mental health care priorities need to
be shifted from psychotic disorders to common mental disorders and from mental hospitals to primary health
centres. Future research needs to focus on the general population, longitudinal (prospective), multi-centre, co-
morbid studies, assessment of disability,
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