INTRODUCTION

ASSESSMENT OF PERCEPTION OF PSYCHOTIC ILLNESS BY QUALITATIVE RESEARCH USING CASE VIGNETTES

What is Psychotic Illness?

Mental disorder

in which the thoughts, feelings, affective response, ability to

recognise reality

and ability to communicate and relate to others are

sufficiently impaired to interfere grossly with the capacity to deal

with reality;

Ref: Kaplan & Saddock Comprehensive textbook of psychiatry 7th ed, glossary p686

Prevalence of Psychotic illness in India

Sl.no
1.

Study
Prevalence of mental disorders of India- H.C.Ganguli et al (Indian Journal of Psychiatry 2000) Study of prevalence of mental disorders in India-S.Murali Madhav et al

Result (Prevalence) 73 per 1000

2.

65.4 per 1000

Problems of Psychotic Illness

Threat to life: A man with serious mental illness is likely to die by age

53, compared with the average life expectancy of 78 years.

C0-Morbidity: People with mental illness are five times more likely to

have a co-occurring medical condition than the general population.

Financial crisis: Untreated mental illnesses increase costs on the

public and private sectors.

Threat to children: Alarming 65 percent of boys and 75 percent of

girls in juvenile detention have at least one mental disorder.

Source: NAMI (National Alliance on Mental Illness)

Perception of Psychotic Illness

People viewed indigenous healing methods as complementary to

allopathic treatments. Multiple and apparently contradictory beliefs on different aspects of psychosis were often simultaneously held by participants. People in the community were more likely to express negative views about mental illness. Relatives of patients with psychosis wanted more support from mental health professionals and community in combating stigma against mental illness. The results indicate the need for better understanding of local perceptions of psychosis.

Source: Perceptions about psychosis and psychiatric services: a qualitative study from Vellore, India Saravanan .B et al.

Why did we choose this topic for our research?

Reason
High Prevalence Wrong perceptions Religious belief as a treatment modality Cultural practices among the people Difficulties in treating people due to religious beliefs

Objectives
To assess the perception of Psychotic illness in the

community.

To study the societal attitude towards psychotic illness

To know the treatment preference for psychotic illness

To assess their knowledge about the cause for such illness. To know their beliefs about supernatural powers.

Reason for choosing Qualitative study for this topic

Being a sensitive issue, we cannot approach people

directly with questions regarding psychotic illness.

When an incident is narrated (by using vignettes) people

tend to imagine ,orient themselves and get involved in the situation narrated to them.
To share their personal experience about the topic

(requires more probing which can be done better in

Qualitative research)

Review of Literature (ROL)

Purpose of doing a review of literature

To identify relevant information and to outline the existing knowledge pertaining to the topic To identify the limitations in context of previous research To give a justification for the study

1. Myths, beliefs and perceptions about mental disorders and health-seeking behavior in Delhi, India
Jugal Kishore, Avni Gupta, Ram Chander Jiloha and Patrick Bantman, Indian journal of Psychiatry

Objective :To assess the myths, beliefs and perceptions about mental disorders and health-seeking behavior in general population and medical professionals of India Methodology : Cross- Sectional study (sample of 436 subjects) Results: Major Perception: Past sins & gods punishment, Polluted air Treatment Perception: Fasting for god or a faith healer can

cure. Very few seeked psychiatrist

2.Community Beliefs About Causes and Risks for Mental Disorders:A Mental Health Literacy Survey in a Rural Area of Maharashtra, India
Michelle Kermode, Kathryn Bowen, Shoba Arole,Kaustubh Joag and Anthony F.Jorm, Indian journal of social psychiatry

Objective: To assess local knowledge and understanding of causes and risks for mental disorders in a rural area of Maharashtra and to assess the prevalence of possible common mental disorders Methodology: A qualitative study using vignettes and a quantitative cross-sectional study. Results: Most common cause - socioeconomic factors Risk group -Women, unemployed and poor people

3. Sociocultural Beliefs And Treatment Acceptance in NIMHANS, Bangalore

Ravi S. Pandey, K. N. Sreenvas, Muralidhar Indian journal of psychiatry.

Objective:To assess socio-cultural beliefs about the causation of mental illness and their future treatment acceptance Methodology: Qualitative research using questionnaire

Results: The commonest responses were Physical causes, sins/wrong deeds (previous life , present life.) The faith-healers are more accepted than psychiatric treatment by patients because the psychiatrist are challenging community's own beliefs.

4. Explanatory Models of Common Mental Disorders among Traditional Healers and Their Patients in Rural South India, Vellore
B. Ravi Shankar, B. Saravanan, K. S. Jacob, Indian journal of psychiatry.

Objective: To delineate concepts, categories, causes of common mental disorders (CMD) and their treatment as understood by traditional healers practicing in rural South India.

Methodology: Focus group discussions(FGD) and in-depth interviews with traditional and faith healers. It is a cross sectional study Results: Different terms, concepts and treatments were used by traditional and faith healers. Mixed anxiety depression the most common diagnosis

5. Public beliefs about and attitudes towards people with mental illness: a review of population studies
Angermeyer MC, Dietrich S, Department of Psychiatry, University of Leipzig, Leipzig, Germany

Objective :To provide a review of population-based attitude research in psychiatry during the past 15 years. Methodology : An electronic search Result : 33 national studies and 29 local and regional studies were identified, mostly from Europe. Although the majority are of descriptive nature, more recent publications include studies testing theory-based models of the stigmatization of mentally ill people, analyses of time trends and cross-cultural comparisons, and evaluations of anti stigma interventions.

Material and Methods

Study Design: Qualitative Study Study Method: In-depth interview using a case vignette Study Period: 3 weeks from 21/01/2013 -09/02/2013

Study Area: Service areas of Muthialpet PHC

Study instrument: Semi-structured questionnaire Standardization of the instrument: Translation of vignette and questionnaire into Tamil and everyone had the same copy Ethical consideration :Verbal informed consent was obtained before

starting our interview

Inclusion and exclusion criteria : Nil

MAP

How we started on doing the study?

1. Introduction to Qualitative Research
Various methods of qualitative research Qualities of a good qualitative researcher(power of observation, patience and many others) What is a vignette and the usage of it in a qualitative research

2. Plan of conducting the Research

We were trained on the usage of a case vignette and questionnaire We were paired as groups (two interviewers per group) and It was planned to do 2 interviews in a day per group Quality of the research: As one of the group member took the interview the other was asked to observe the interview process and to take note

3. Conducting the interview

First we introduced ourselves and told the purpose of the interview Verbal informed consent was obtained Rapport was created

In the beginning, we read the vignette in a neutral attitude

The questionnaire was administered in Tamil We were monitored while interviewing and were rectified Preparation of the transcript was started from the first day of the interview

Data entry and analysis

Quantitative Software used for entry: Epidata Parallel data entry was done Cross checked to reduce error Total no of forms: 189 Software used for analysis : SPSS (version 16) Frequency and percentage were obtained and interpreted

Qualitative :
We compiled all transcript into a master transcript Multiple reading of transcript was done Text was decontextualised and deductive codes were made Manual content analysis was done and themes were generated

RESULTS QUANTITATIVE ANALYSIS

HOW WE DID THE QUANTITATIVE ANALYSIS

We divided ourselves into 2 groups of 20 each Each group entered 189 forms in EPI DATA sheet

separately which was compared for validation

We did this to reduce the chance of error Analysis was done in SPSS software (Version 16)

Table no.1: Perception of psychotic illness among the study participants (N= 189) Q:What do you feel about this condition?
Category Sounds to be dangerous (n=186) Response Yes No Appears to be curable (n=187) Effects of wrong deeds (n=186) Yes No Yes No Happens only to bad persons (n=186) Yes No Number 135 51 172 15 81 105 19 167 % 72.6 27.4 92.0 8.0 43.5 56.5 10.2 89.8

Table no.2: Perceived Cause of the psychotic illness (N = 189) Q: What do you think could have caused this?
S.No Cause Number %

1.
2. 3.

Accidental injury
Brain disturbance Addictions

61
86 37

32.3
45.5 19.6

4.
5. 6. 7.

Disturbances in family
Stress/tension at work Genetic/familial Others *

122
101 30 76

64.6
53.4 15.9 40.2

* Others included fear, seeing shocking incidents, bad deeds done by the parents and ancestors etc. # Includes multiple responses: Do not add to 100%

Chart No 1: Factors affecting the psychotic illness

Q: What among the following might affect this condition?
40 35 30 25 20 15 10 5 0 Social status Occupation Religion Others # Includes multiple responses: Do not add to 100% 22.8% 27.8% % 35.4% 34.9%

# Multiple responses are possible

Bad incidents Evil powers & black magic Bad deeds

Books &stories

Other factors associated with psychotic illness

Love failures

Depression

Negative thoughts

Mental disturbance

Marital disharmony

Chart 2: Societal attitude towards people with psychotic illness (N= 188)
Q: How do you feel about the societal attitude towards this problem?

POSITIVE

30.4% (57)

34% (64)

NEGATIVE
NEUTRAL

35.6% (67)

Table 3: Community opinion about violence/abuse towards people with psychosis (N= 186)
Q: Do you feel that people suffering from such illness are subjected to abuse/violence from the society?

S.No

Response

Frequency

1. 2. 3.

Agree Dont know Disagree

122 19 45

65.6 10.2

24.2

Community Perception about hidden identity of the people with psychosis (N= 187) Majority (71%) agreed to the above response and the possible reasons were as follows, 9%
Stigma

47% 44%

Isolation Others

Others: To avoid problems during marriage, for family respect, fear of society etc.

Perception of study participants about the treatment of psychotic illness (N=189) Response: Yes it can be treated (majority, 99%) Table 4: Perception of study participants about the place of treatment of psychotic illness
S. No
1 2 3 4

Response
At home Faith Healers Hospitals(doctors) Others

Frequency
18 55 157 20

%
9.5 29.1 83.1 10.6

# Includes multiple responses: Do not add to 100%

Q: Can you recall similar incident in your life( either own family members or outsiders)? N = 185

56 54 52 50 48 46 44 42 40

54.1%

Yes No

45.9%

Perception of causes of psychotic illness

Punishment by god Evil spirits Unsatisfied ghost Black magic Stepping on lemons Going to places with ghost

Pertaining to supernatural powers

Horror stories and program Movies Childhood fairy tales and horror stories.

External influences

Personal and emotional

Stress Family problems failures Shocking incidents Negative thoughts

Scientific
Hormonal imbalance Neuronal problems Brain damage

Support Education

Love Care

Positive
Sympathy Treatment Societal attitude towards persons with psychotic illness Negligence Criticism Isolation Abuse Violence

Negative
Burden

Perception about the severity of psychotic illness

NOT DANGEROUS Care from family As its curable Medical problem DANGEROUS

Psychotic illness
Gender preferences Males Females

Suicide prone For future Torture by faith healers Violence Emotional instability Superstitions

Involved in work Strong minds Less of blind approach

Sitting idle Sexual abuse No marriage proposal Fragile minds

Societal perception about the concealment of identity by psychotic individuals

Not concealed

SELF IDENTITY

Concealed

Feel free to come out because

unaware of their acts For the peace of mind

stigma
Rural area

Family support

isolation

prestige

Societal perception about treatment of psychotic illness

Emotional support Motivation Give confidence Do not criticize Love and care Do not isolate Yoga Ashram Cinema hall New and peaceful environment Economic support Asylum or rehab center Publish ads Pray for them Fate Nothing can be done Govt. help Heals on its own

Allopathic Rx
Electric shock

Neurologist
Psychiatrist

Alternative medicine

Faith healers Neem leaves Chaining them torture Sacrificing animals to evil spirits Pooja on new moon day Temple Mosque Holy thread

The haunting
Pratibha: 21 yrs lives with her family Possessed by an evil spirit 4 months ago when walking alone at midnight. Strange behavior- change in voice-crying- refused to take food- hit herself to wall. Family members- worried took her to Mel Malayanur temple Pratibha ill treated- beaten with brooms- neem leaves- tongue pierced- ash blown on face, etc.

I have seen similar incident when I was in cuddalore. A girl of 15yrs of age who was my neighbour lived with her father, mother and grandma. Her grandma was not well for some days then she died one day.

After that the girl tend to behave abnormally she used to run on the road, used to speak meaningless words, not interested in eating and dressing. This continued to happen for 1 month . Parents didnt bring the girl to hospital

They invited one faith healer from Kerala to their home.

Faith healer told that the girl was possesed by the soul of her grandma because she had seen the last breath of her grandma. Then the faith healer did one pooja and tied one Thayathu over the girls hand . After that girl recovered gradually over a period of time then family shifted their house to chennai due to fear of evil spirit.

Narration 3
SNAKE BITE STORY

Superstitious belief
A boy loved a girl since childhood. He was bitten by a snake and died-10 years. Girl attained puberty, aftr that stared behaving strange. Soul of the dead boy entered the girl's body. Complains of fear and pain. Faith healers. Hospital. 90 percent cured.

Narration 4

 The respondent shared a similar incident, which happened in his friends life. His friend had a great belief in horoscope . His friend believed that the day in which a person takes birth decides the happiness or sadness of his or her life. He thought that he was not born on an auspicious day and thats a reason for his sorrows and sufferings. There is a voice in him which says him to commit suicide on a

Particular day so that his soul will take a rebirth on an auspicious day and his life will be filled with happiness and joy. So he has tried to commit suicide many times but he was saved by his family members . Finally he went to some other city and stayed there in a lodge and commit suicide.

Conclusion
91% of the participants felt that the condition is

curable.( n=187 ) 35.4% of the participants feel that social status might affect this condition. According to 35.6% of the participants, societal attitude is negative towards this condition.(n=188) 98.9% feel that this condition needs to be treated and 83.1% feel that this condition should be treated at hospital while 29.1% feel that it should be treated by faith healers.(n=189)

Conclusion
To build up rapport with people

To respond to peoples emotions

Ways to make the person comfortable(By making

them sit) The methods of putting questions to get the best response The art of probing The various cultural beliefs in the minds of people We realized the importance of patience