The International Journal of Psychosocial Rehabilitation
 

Functioning and needs of patients with chronic mental illness
attending a community mental health clinic in South India.

 
Kurian Jose, PhD scholar
 TATA institute of social sciences (TISS), Mumbai, India, , Email: kurianjomanayil@gmail.com.
 
Rajith. K. Ravindren
 Assistant professor, Department of psychiatry, Institute of Mental health and Neuro-sciences (IMHANS), Calicut, Kerala, India, , Email: rajith.mail@gmail.com
 
Shibu Kumar,
Assistant professor, Department of psychiatry, Institute of Mental health and Neuro-sciences (IMHANS), Calicut, Kerala, India, Email: shibu.atheist@gmail.com
 
P.K.Raheemudheen
Clinical psychologist, Department of psychology, University of Calicut, Kerala, India, Email: raheempsych@gmail.com.

N.A.Uvais
 Department of Psychiatry, IQRAA International Hospital and Research Centre, Calicut, Kerala, India, Email: druvaisna@gmail.com
 




Citation:
Jose K, Ravindren RK, Kumar S, Raheemudheen PK & Uvais NA. (2017)
  Functioning and needs of patients with chronic mental illness attending a community mental health clinic in South India.
.
International Journal of Psychosocial Rehabilitation. Vol 21 (1) 88-95


Corresponding Author:
Kurian Jose, PhD scholar
TATA institute of social sciences (TISS)
 Mumbai
India
 Email:kurianjomanayil@gmail.com.

No conflicts of interest
No financial supports

Abstract
Backgrounds & Objectives: One of the major challenges in the mental health care is the recovery from the mental illness. Understanding functioning and needs of the persons with mental illness is one of the tools through which the rehabilitation plans can be made effective.
Methods: Out patients ( 54) attending the Community Mental Health Programme (CMHP),  at Thalkulathoor, a village in Kozhikode district of Kerala, India, was selected as study group. Pre-printed survey based questionnaire were administered to the patients who attended the community clinic. The study is a single contact, cross-sectional study.
 Results: In the domains of   role functioning 77.8% of them were unable to make decisions regarding themselves or regarding the family matters and supervising family. 72.2%    of the sample was unable to earn money and handle them. Majority   of the selected sample (81.5 %) lacked problem solving skills and 70.4% had problems in maintaining interpersonal relations  
Interpretations and conclusion:  The research looks into the deficiencies in the life of  mentally ill  in the community and  adopting  remedial measures through rehabilitation.

Key words: Functioning, needs, chronic mental illness, psychosocial rehabilitation

Introduction:
Needs of men are varied and complex in nature. Due to a variety of reasons including stigma, economic deprivation and fluctuations in clinical conditions, people with mental illness often fails to meet their socioeconomic and other needs. People with chronic mental illness has various problem areas like  lack of personal achievement, lack of job, difficulty in forming and maintaining relationships, loneliness, health problems, lack of leisure activities, personal safety, and looking after themselves (Lambri et al. 2012). Recent studies evaluating needs of patients with schizophrenia found that needs were not adequately met in one in four patients and fewer community based rehabilitation services are found to be associated with more unmet needs ( Kovess-Masf´ety et al. 2006) .

Recovery oriented community based mental health services in various parts of the globe has recognized the importance of a need based approach towards care provision for individuals with chronic mental illness. Identifying unmet needs, which results in reduced health, poor quality of life and ongoing health related expenses, can provide information for gaps in services and implications for improvement (Slade et al. 1998).

While evaluating needs, research has shown the importance of a combined evaluation of functioning and individual need assessment along with clinical status, quality of life to inform service provision (Slade et al. 1999). Hence, quantifying functioning and identifying need at a local level for people with chronic mental illness is important to enable providers and patients to access a wide range of possible solutions with respect to the unmet needs. The present study is a small step in those directions in the specific Kerala context in reaching out to the persons with mental illness in community to know their needs and functioning.

In Kerala, one of the most developed states in India, the treatment for mental illness is provided by Psychiatric institutions, teaching hospitals, multi-speciality hospitals, private psychiatry clinics and district community mental health programmes. Community mental health programmes such as National mental health programme, District mental health programme and community mental health programme were started with the objective of reaching out to the mentally ill near their residence and currently a significant number of patients utilize the community mental health services initiated by Institute of mental health and neurosciences (IMHANS), Calicut. Moreover, NGOs play a pivotal role in the rehabilitation of the mentally ill in coordination with department of health, social justice and local government bodies by running residential care, vocational rehabilitation and day care facilities.
 
Materials and methods:
The current study is a community based single contact, cross-sectional study conducted at a community psychiatry clinic, run by IMHANS with the help of a support group, at Thalakulathoor, a village in Kozhikode district of Kerala. The sample population was selected from the patients who regularly visit the Clinic. Informed consents were taken either from patient or from the immediate care givers.   Informations were collaborated with the main care givers to ensure that they are relevant and reliable. Necessary socio-demographic data was collected and a Performa was filled based on the three main domains of global functioning, vocational environment and vocational needs, and resource management. The Performa was prepared after an extensive research review so that the items are suited to the selected population.  The research team referred the available tools such as Rehabilitation Needs Assessment Schedule (Nagaswami et al., 1985), Client’s Needs Assessment Schedule (CASIG) (Wallace et al., 2001) and   functional assessment (Liberman, 2008), and found out areas and domains of assessment. Based on such reference the research team developed a Performa hoping to be suitable for the population selected. The data was collected by a team of mental health professionals. The data was analyzed by SPSS 17.
 
Results
The survey evoked good support from care givers, patients and the support groups. Among of the total population the 53.7% were males, minimum level of education was primary (44.4%), 83.3% were unemployed and 57.4% were unmarried. Schizophrenia was found to be leading diagnosis (43.3%).  Majority of the patient and care givers (90.7%) have expressed to have positive approach towards treatment and 96.3% of them pay regular visit to Community Mental Health Programmes (CMHP) clinic (see Table 1 A &B). In Kuppuswami’s Socio-economic status scale it was found that 60.8% of them belong to upper lower income category (see Table 2).

Table 1A :Socio-demographic profile of the sample population ( Continuous variables)

 

Variables

Mean ± S.D

Minimum

Maximum

 

Age (In years)(no=54)

45.80± 13.26

15.00

70.00

Duration of illness (no=50)

22.42± 10.82

5.00

47.00

 
Table 1 B: Socio-demographic profile of the sample population  ( Categorical variables)

Variable

 

Frequency(no:54)

     %

Gender

Male

29

53.7%

Female

25

46.3%

Vocational Status

Employed

9

16.7%

Unemployed

45

83.3%

 

Name of the illness

Schizophrenia

24

45.3%

Depression/ Mania/BPAD

12

22.6%

Psychosis

6

11.3%

MR and other neurological disorders

11

20.8%

Approach towards treatment(Patient or caregivers)

Positive

49

90.7%

Negative

5

9.3%

Regularity

Regular

52

96.3%

Irregular

2

3.7%

Current residence

Own house

41

75.9%

Rent house

5

9.3%

Relatives home

2

3.7%

Rehab centre

5

9.3%

Street or other

1

1.9%

Structure of family

Nuclear family

38

70.4%

Joint family

9

16.7%

Extended family

4

7.4%

Living  in residential facility

3

5.6%

Main Caregiver

Parents

13

24.1%

Wife/husband

17

31.5%

Children

6

11.1%

Other

18

33.3%


Table 2: Kuppuswami’s Socio-Economic Status Scale

Variable

 

 

Frequency

 

%

Socio-Economic Status

Upper Middle

2

3.9%

Lower Middle

10

19.6%

Upper Lower

31

60.8%

Lower

8

15.7%



In all the domains of personal hygiene and maintenance, communication skills and social relationship the current study found that majority of them had no difficulties, but in the domains of role functioning 77.8% of them were unable to make decisions regarding themselves or regarding the family matters and supervising family. It was found that 72.2% of the sample population was unable to earn money and handle them. Majority (81.5 %) of them   lacked problem solving skills and 70.4% of them had problems in maintaining interpersonal relations (see Table 3 A & B) In all the domains of leisure majority were unable to engage in activities that require the use of physical and mental capacities such as watching cinema (57.4 %) and listening to music (see Table 3 C).

Table 3  A: Global Functioning : Communication Skills

Variable

 

Frequency (no:54 )

%

Minimum Communicate with   people

Yes

50

92.6%

No

4

7.4%

Answers to questions

Yes

48

88.9%

No

6

11.1%

Expresses needs

Yes

40

74.1%

No

14

25.9%

Enquires about near and dear ones

Yes

28

51.9%

No

26

48.1%

Involves in discussions on public interest

Yes

8

14.8%

No

46

85.2%

Table 3 B : Global Functioning : Social Relationships, role functioning

Variable

 

Frequency (no:54 )

%

Maintains good relation with family

Yes

39

72.2%

No

15

27.8%

Maintains good relation with treating doctor

Yes

38

70.4%

Maintains good relation with  neighbors

No

16

29.6%

Yes

30

55.6%

No

24

44.4%

Maintains good relation with friends

Yes

21

38.9%

No

33

61.1%

Decision Making and supervision of family

Yes

12

22.2%

No

42

77.8%

Looking after unwell family members

Yes

22

40.7%

No

32

59.3%

Earning money and handling

Yes

15

27.8%

No

39

72.2%

Problem Solving

Yes

10

18.5%

No

44

81.5%

Emotional Support

Yes

15

27.8%

No

39

72.2%

Maintaining interpersonal relations

Yes

16

29.6%

No

38

70.4%

 

Table 3 C: Global Functioning: Leisure

Variable

 

Frequency (no:54 )

%

Physical Exercise

Yes

9

16.7%

No

45

83.3%

Cinema or drama

Yes

31

57.4%

No

23

42.6%

Listening  to music

Yes

36

66.7%

No

18

33.3%

Reading books

Yes

10

18.5%

No

44

81.5%

Phoning friends

Yes

13

24.1%

No

41

75.9%

Spending time with friends

Yes

9

16.7%

No

45

83.3%

 


Discussion: In Indian scenario, recovery oriented psychiatric rehabilitation is an emerging field. Recovery oriented rehabilitation services can only address the enormous difficulties faced by the professional and non-professional groups in the rehabilitation of the mentally ill (Anthony, 1993). Any rehabilitation initiative require a prior assessment of the needs of the patients with mental illness under their care as it is the cornerstone of all interventions for a person with psychiatric disabilities (Corregan et al. 2008).

 Hence, the present study may be one of the first such attempts in Kerala in reaching out to the persons with mental illness in community to know their needs and functioning.
In the current study the majority of the population selected was unemployed; indicating that long standing chronic illness has significant impact on the life course. Majority of the patients stay at home idle most of the time, which can worsen the mental health status and delay the chances of recovery, leading to reduced chances of early reintegration to the community (Drake et al., 1999 & Provencher et al., 2002). Majority of such patient hail from nuclear family indicates that such patients will have higher economic dependency on other family members, especially when they are unmarried and belongs to poor socio-economic status (Mini, 2012). Since many of them have first degree relatives as their main caregivers, they may be at risk of isolation and neglect on the event of their death or other major life events, leading to increased need of institutional care or protection in the future.

The current study also found that most of the study population lack skills in effective role functioning, which might be due to the chronic nature of illness and associated social exclusion forcing them to withdraw without adequate role functioning (Glenn et al., 2006). The lack of effective communication skills in the study population compound the problem of role functioning and indicates the lack of leadership qualities and poor problem solving skills. Hence, the social skills assessment can be beneficial in finding out the needs to improve the social functioning (Bellack et al., 1997).

Our study also revealed that most of the study population spends their leisure time in watching TV or listening to music which do not require the use of intellectual capacity. Mentally ill persons with less productive engagements may become aware of their disabilities, leading to negative thoughts resulting in self imposed sedentary life style, resulting in further deterioration in cognitive functioning (Gold, 2004). A detailed and specialized assessment of the current study population can further reveal the gravity of the cognitive impairments contributing to functional, social, or vocational problems (Spaulding et al., 2003).

In the domain of resource management, majority of the study population lack the basic knowledge to handle money, probably due to the attitude of over protection from the family, resulting in loss of autonomy of the patients over money management (Lecomte et al., 2005).

Hence, the current study clearly emphasize that the patients with mental illness living in the community need improvements in their impaired social and life skills to reduce stigma, while continuing pharmacotherapy (Mueser et al., 1991). Since, stigma and social exclusion still highly prevalent in the communities, the formation of local supportive groups for rehabilitation initiatives are the need of the time, especially for evaluation, monitoring of patients needs and stigma alleviation.

Hence, integrated approach of recovery oriented rehabilitation initiatives alongside the   ongoing medical supervision can be effective in re-integrating the persons with mental illness to the main stream of their community. In Indian scenario the importance of recovery oriented rehabilitations is yet to be acknowledged.  Hence this study has the following implication:

•         Policy making is necessary for the rehabilitation of mentally ill.  Medical model of treatment along with recovery oriented rehabilitation is to be recognized as best effective management model for patients with severe mental illness, by the policy makers in the governments. Persons with mental illness need the support from the government as majority are neglected by their family and community.

•         Government local body funds for the disability management and rehabilitation can also be effectively utilized for better locally supported professionally monitored recovery oriented rehabilitation initiatives.

•         There is an urgent need for   further research on practical, effective and successful models   in the area of recovery oriented rehabilitation. 

•         Since recovery oriented rehabilitation can be successful only with the support of community, community support group formation is a must. Strengthening voluntary Supportive groups for mentally ill’s care and support,  formed  in line with Palliative care units in most part of Northern Kerala is needed in bringing changes about attitude, alleviation of stigma, community day care, vocational training and engagements of mentally ill. Their support needs to be acknowledged and encouraged.

•         An assessment tool  assessing the  needs of mentally ill with culturally appropriate and covering the large domains of needs of patients with mental illness is  to be developed to enable the process of rehabilitation. 
 
 
Conclusion
A few areas of deficiency in the life of chronically mentally ill   are identified in this study. Unmet needs of the persons with mentally ill in India are many and needs a lot of enquiry using both  qualitative and quantitative methods.  Though rehabilitation  initiatives have been started  many years back, intensified  recovery oriented rehabilitation is  yet to reach to the majority of the patients who live in residential facility and  in the community. Owing to the high patient intake  and lack of professional  man power remain  hurdles in the rehabilitation initiatives of these patients. Above all there aren’t clear data on the rehabilitation needs of those persons who undergo the treatment, either  staying with  their family of origin or at the residential care.  As there are no data available, the government agencies find it difficult to frame a policy suitable for the rehabilitation of mentally ill. 

Note: The community based treatment options  launched by IMHANS, under National Rural Health Mission( NRHM) program  is an integrated program for both pharmaco- therapy and psycho-social interventions, ( Krishnakumar, 2010). This   program   has a good  support group   lead by dedicated volunteers  both  trained and committed.  
 

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