Girindrasekhar Clinic, Calcutta
College of Science & Technology, Calcutta University
Peeless Hospital, Calcutta
Rankrishna Mission Seva Pratishthan, Calcutta
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Correspondence: D. N. Nandi, P-535, Raja Basant Roy Road, Calcutta-700 029, India
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ABSTRACT |
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Aims To assess the changes, if any, in the prevalence of mental disorders in a rural community after an interval of 20 years in the context of its changing socio-economic conditions.
Method A door-to-door survey of the prevalence of psychiatric morbidity in two villages was conducted by a team of psychiatrists. The survey was repeated after 20 years by the same team and by the same method. Changes in the mental health status of the community were compared.
Results Total morbidity per 1000 fell from 116.8 to 105.2. Morbidity in men fell from 86.9 to 73.5 per 1000 and in women from 146.8 to 138.3 per 1000. Rates of anxiety, hysteria and phobia had fallen dramatically and those of depression and mania had risen significantly.
Conclusion The level of psychiatric morbidity showed no statistically significant change. The morbidity pattern (relative proportion of type of morbidity), however, showed some interesting changes. Similar studies should be done on a larger sample.
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INTRODUCTION |
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To assess the changes in the mental health status of an Indian rural community after a long interval, Nandi and colleagues surveyed the same community after 10 years and determined the prevalence of mental disorders in the context of the changing socio-economic status of the community (Nandi et al, 1986). This study showed that the level of morbidity had not changed significantly after one decade. We now wanted to verify whether this pattern is maintained after two decades.
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METHOD |
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Sample
All the families of the village of Gambhirgachi, situated in the district
of North 24 Parganas (60 km from Calcutta), and all the families of the
village of Paharpur in the district of Bankura (32 km from its nearest town)
constitute our sample. These villages are situated in the agricultural belt of
West Bengal and most of the families live by cultivation. The
socio-demographic characteristics of the villagers are presented in the
Results section, below.
The language used by the villagers, as well as by the voluntary workers, was Bengali, so there was no communication gap or barrier between the two. Culturally, the fact that D.N.N. himself came from a rural background in West Bengal was of significance.
Method
Four schedules were prepared to collect and tabulate the data, as
follows:
For an operational definition of a case, that in the World Health Organization Technical Report Series (1960) No. 185 was taken as a model, and a minor alteration was made in consultation with six other psychiatrists; the modified version used in the survey resulting was as follows:
A manifest disturbance of mental functioning specific enough in clinical character to be consistently recognisable as conforming to a clearly defined standard pattern and severe enough to cause at least partial loss of working or social capacity or both of a degree which can be specified in terms of decrease in quality and/or quantity of work or of the taking of legal or other social action.
For the formulation of a diagnostic criterion, for each disease the same procedure was followed. Only those who were suffering at the time of examination were accepted as cases, except when the diagnosis was hysteria or epilepsy. In these two instances, manifestation of symptoms at any time during the preceding year was sufficient for inclusion as a case.
Collection of data
A door-to-door enquiry was made to each family. The data were collected
first from the head of the family and again from each adult member of the
family, to cross-verify that all the facts had been obtained. Whenever a
probable case was detected, a thorough examination, both physical and
psychiatric, was made by two senior psychiatrists of the team separately, who
made their diagnosis independently. In the event of a divergence of opinion
between the two psychiatrists, the case was re-examined and a diagnosis
agreed. Cases of divergence of opinion were very few. The psychiatrists had a
high level of interrater agreement.
The principal investigator (D.N.N) and three other members of the team who conducted the second survey in 1992 are the same as those who made the first survey in 1972. One of those three (S.P.M.) was the statistical advisor; the other two (G.B. and A.G.) were senior psychiatrists. They took part, along with the principal investigator, in the examination of all probable cases and in diagnosis, in accordance with the diagnostic criteria determined before the beginning of the first survey. The new members of the team (P.S.N. and S.N.) are qualified psychiatrists. They were trained in the use of the tools which were used in both these studies, but they were relatively junior and did not take part in the diagnosis of the cases.
The core of the team, who carried out the examination and diagnosis, was the same in both the surveys (conducted in 1972 and 1992). They followed the case-finding methods and the diagnostic criteria strictly and made the diagnosis in the same way in both the surveys. This strategy was adopted to ensure the comparability of rates of morbidity.
The data obtained by each survey were compiled and computed and variables were dealt with statistically.
Statistical methods used
Data were mostly presented in two-way tables, and the possible association
between two classification factors likely or hypothesised to be mutually
associated was tested for significance using the standard 2
tests in contingency tables with k categories for one factor and
L for the other. The value of the
2 statistic
obtained was compared with the tabulated percentage ones corresponding to
(k-1) x (L-1) degrees of freedom. In a few situations,
associations between two factors were tested by using the z-test.
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RESULTS |
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The distribution of families according to socio-economic status shows that in course of 20 years this has improved. In 1992 the percentage of families in Classes I and II increased, and that in the lowest classes decreased. This change is statistically significant.?
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The distribution of affected families according to socio-economic status shows that the higher classes had higher rates of morbidity in both 1972 and 1992. In 1992, however, the trend is not so clear-cut as in 1972. The difference in rates of morbidity is, however, statistically not significant.
Table 6 shows that the rate of morbidity was higher in women than in men in the base year (1972), and this trend was not changed significantly after 20 years.
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Table 7 shows that the rate of morbidity in the younger age group (under 23 years) has dropped remarkably over the 20 years (from 29.3% to 18.0%). On the other hand, morbidity in the elderly group (over 60 years) has increased significantly.
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The distribution of different types of illness is shown in
Table 8 as rates per 1000. The
difference between the morbidity rates in 1972 and 1992 by diagnosis is
statistically highly significant (=11.1746, d.f.=9,
P>0.01).
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The Z-test of the rates in each diagnostic category at the two points in time indicates that the difference is statistically highly significant for anxiety, hysteria, phobia, depression, and epilepsy. The difference in the rates of mania is significant at the 5% level. Except for depression and mania, each diagnostic category showed a downward trend in morbidity.
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DISCUSSION |
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In this context the prevalence figures obtained by us in two surveys conducted 20 years apart deserve careful consideration. The core team members and the method followed in both the surveys are the same. The almost identical rates of mental morbidity (116.8 and 105.2 per 1000) (Table 4) observed after 20 years may suggest that the community has maintained a remarkable stability in its total mental morbidity over the years. In their longitudinal study of the natural history of mental disorders, Nandi et al (1978) identified two categories of opposing factors which regulated this stability. One category increased the morbidity rate: viz, the incidence of new cases and migration of sick people into the village. Factors causing a decrease of the morbidity rate were: (a) recovery of cases; (b) death of cases; (c) migration of sick people out of the village; and (d) an increase in the number of healthy people due to birth and migration. The popular notion that mental disorder is on the increase is not borne out by the data obtained by us in this rural survey.
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Gender distribution
In 1972 women showed a higher rate of mental morbidity than men. After two
decades this pattern had not changed: the higher rate of morbidity in women
persisted. Many field studies conducted in different parts of India have shown
this greater vulnerability of women to mental illness
(Sethi et al, 1967;
Dube, 1970;
Nandi et al, 1975).
The point to be emphasised here is that this pattern has remained stable over
a long period of time (1972, males 86.9 per 1000; females 146.8 8 per 1000;
1992, males 73.5 per 1000; females 138.3 3 per 1000)
(Table 6). One should not,
however, miss the important fact that there is a downward trend in the
prevalence of mental disorder in both men and women (men: <13.4 per 1000;
women: <8.5 per 1000). Though this trend is not statistically significant,
either within group or between groups, it may assume some importance in the
coming decades. Women, having a higher morbidity rate, are showing a slower
rate of decrease over a given period of time.
Age distribution
The age distribution of the affected persons in 1972 and 1992 shows that
the rate of morbidity was higher in the under-23 years old age group in 1972
than in the corresponding age group in 1992 (29.3% and 18% respectively)
(Table 7). The morbidity of the
older age group (aged 48 years) is in clear contrast to this pattern: in
1972 it was 29.5%, while in 1992 it rose to 41.7%. It must be pointed out that
this shift in the pattern of morbidity by age did not significantly alter the
total morbidity of the community after 20 years. So, one may presume that the
younger age group in this community became a mentally healthier group in the
course of time. Could this be associated with the change in the general
outlook of the community, with better prospects for jobs, shelter, medical aid
and income generation? This point requires exploration.
Type of illness
The rates of depressive illness and mania have increased significantly over
the years, but the rates of anxiety, hysteria, epilepsy and phobia have
declined (Table 8). The
increase in the rate of mental deficiency (though statistically not
significant), and the significant fall in the rate of epilepsy may be partly
explained by improved medical care and maternity and child welfare measures
which have become available in the community during the last 20 years, which
will have increased the longevity of the mentally retarded and also decreased
one of the potent causes of incidence of epilepsy. In one of our previous
studies (Nandi et al,
1992) we have drawn attention to the persistent downward trend in
the rate of hysteria in a rural community over the years and postulated (on
the basis of available data) that this may be associated with a persistent
rise of the economic status of women in that community.
The social constructs regarding the mechanism of symptom formation postulate that symptoms have special meanings in relation to the shared belief of a community about the nature of an illness (Murphy et al, 1964). In cases of hysteria in the community under study (the majority of whom are women), the dramatic abnormal behaviour is perceived by significant others as the manifestation of a major disorder. Women often live in a state of economic dependence forced on them by the family and by society at large. Being stricken by a major illness such as hysteria often ensures attention and softens strong expressions of emotion from members of the family.
The relationship between the economic dependence of women and their vulnerability to hysteria deserves careful scrutiny. In a study of contagious hysteria in a village near Calcutta, Nandi et al (1985) found that the frequency of seizures decreased during the last three years of a decade of illness. During this period women were allowed, for the first time, to work outside their homes for a wage, and they became economically less dependent on their husbands. As the women's self-confidence increased, their episodes of hysterical fits declined. In their survey of several villages in West Bengal, Nandi et al (1980) found a higher rate of hysteria in the lower socio-economic classes.
The rise in the rate of depression is consistent with the findings of other recent studies reviewed by Singh (1979) and by Nandi et al (1992). The change in lifestyles and in the inner life of the people in an upwardly mobile society during the last 20 years is unmistakable. In a recent study of both Indian and Western patients with depression (Ananth et al, 1993), it was found that 62% (74 out of 119) of the Indian patients suffered from guilt as compared with 84% of the Western patients (96 out of 114). Studies conducted in the 1960s and 1970s reported a low prevalence (varying between 5.3% and 26.7%) of guilt feelings in Indian patients with depression (Murphy et al, 1964; Venkoba Rao, 1966; Bagadia et al, 1973). Carstairs & Kapur (1976), in their survey of a rural community in Karnataka, India, found that the rate of depression was 30.0 per 1000; Nandi et al (1992) reported that the rate of depression in a village in West Bengal rose from 37.7 per 1000 to 53.3 per 1000 after an interval of 10 years.
The declining prevalence of phobia, to the extent that it has almost disappeared from the community under study, is an enigma.
Socio-economic status (SES)
The SES scale used in the survey showed a significant change in the SES of
the community over the course of time (20 years). There was a trend of upward
mobility of the families in 1992 (Table
2). Hints of this upward mobility are in the indices of SES
recorded in Table 1. The spread
of education, improved health facilities and better inputs (seeds, irrigation,
fertilizers, insecticides) in farming must have influenced the quality of life
of the people. But this had little impact on the distribution of affected
families in different classes (Table
5). In 1972, the higher classes had higher rates of affected
families. The pattern in 1992 was similar. The rate of families affected in
the two upper Classes (I and II), taken together, was higher than that in
Classes IV and V (though statistically not significant). It is, therefore,
evident that the pattern of higher rates of morbidity in higher classes is a
stable characteristic of this community and is maintained over the course of
time, but one should not read too much into it, as the difference in morbidity
falls short of statistical significance. In this context it may be noted that
in one of our earlier surveys of a group of villages in West Bengal
(Nandi et al, 1979)
the prevalence of mental morbidity was found to be higher in the higher
classes. In his follow-up study of a sample of population surveyed by
Essen-Moller in 1947 (Essen-Moller,
1956), Hagnell was able to confirm this finding in relation to
social and economic classes both at the beginning and the end of the 10-year
follow-up period (Hagnell,
1966).
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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Received for publication March 10, 1998. Revision received September 6, 1999. Accepted for publication September 7, 1999.
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