Disability assessment in mental illnesses using Indian Disability Evaluation Assessment Scale (IDEAS)
Background & objectives: Psychiatric disorders cause disability in individuals and pose significant burden on their families. In most of the cases residual disability and poor quality of life continue even after disability evaluation in patients with chronic mental illness in very important. The present study was undertaken to assess and compare the disability in patients with schizophrenia and obsessive-compulsive disorder (OCD) using Indian Disability Evaluation Assessment Scale (IDEAS).
Methods: Patients diagnosed to have schizophrenia and OCD with mild severity of illness were included in the study. Indian Disability Evaluation Assessment Scale (IDEAS) was applied. Disability was assessed in these patients on all domains of IDEAS.
Results: Majority of the patients with schizophrenia were from rural areas whereas most of the patients with OCD were from urban background. There was comparable disability in the patients with schizophrenia with duration of illness in the range of 2-5 yr and >5 yr. Significant disability in work and global score was seen in patients of obsessive-compulsive disorder with duration of illness >5 yr. Patients with schizophrenia had significantly higher disability in all domains than patients with OCD.
Interpretation & conclusion: Schizophrenia causes greater disability than obsessive-compulsive disorder in patients. These illnesses affect all areas of daily functioning leading to greater disability, and thus increasing the burden on the family, pose greater challenge for the rehabilitation of patients and their inclusion in the mainstream of the family and society. Further studies on a larger sample need to be done to confirm the finding.
Key words Disability – IDEAS – obsessive-compulsive disorder – schizophrenia
Psychiatrie disorders are one of the most common and prevalent illnesses that widely affect world population accounting for nearly 31 per cent of world’s disability. Five of the 10 leading causes of disability worldwide are in the category of mental disorders: major depression, alcohol use, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder1. Psychiatric illnesses like schizophrenia, bipolar affective disorder and obsessive-compulsive disorder, impact negatively on the academic, occupational, social and family functioning of the patients.
It has been demonstrated that in the patients of mood and anxiety disorders, residual disability and poor quality of life continue even after completion of symptom-linked treatment2,3. There is amelioration of symptoms with pharmacotherapy, but social functioning and quality of life improve only with concerted efforts at rehabilitation that take longer intervals of time4.
Research initiatives in the area of assessment of disability in patients with schizophrenia in India have focused attention on two important issues: firstly, development or modification of scales for assessment of disability and secondly, disability evaluation in persons suffering from chronic mental illnesses. Disability has been assessed in psychiatric patients in different settings such as in hospital-based sample5,6 in community7,8, and also in follow-up studies9-11.
We undertook this study to assess, quantify and compare the disability using Indian Disability Evaluation Assessment Scale (IDEAS) in patients suffering from schizophrenia and obsessivecompulsive disorder attending a tertiary care hospital in north India. This study has been carried out as an attempt to assess impact of mental illnesses on different domains of patients life. This would help to understand, plan and expect accordingly and appropriately as far as their management and rehabilitation is concerned. Schizophrenia being a psychotic disorder and obsessive-compulsive disorder being a neurotic disorder, were chosen so as to compare their disabling potential.
Material & Methods
Patients attending outpatient section of Department of Psychiatry, King George Medical University, Lucknow, India, duing the period between August 1, and October 31, 2001, were screened to include in this cross-sectional study. Those diagnosed to be suffering from schizophrenia and obsessivecompulsive disorder by ICD-IO DCR12, with duration of illness of minimum two years without any exacerbation or hospitalization, and accompanied with a primary care giver were assessed further. Patients having only mild severity of illness on Clinical Global Impression13 Scale were included so that it could be assessed whether the instrument -IDEAS14 can pick up disability in illness of mild severity. All patients with co-morbid medical and psychiatric illness, likely to contribute in disability, were excluded. Informed consent was taken from the primary care giver. The target was to include about 30 consecutive patients for each illness. IDEAS was applied in all the patients who fulfilled the selection criteria to measure the disability.
IDEAS is best suited for the purpose of measuring and certifying disability. It has four items: Self Care, Interpersonal Activities (Social Relationships), Communication and Understanding, and Work. Each item is scored between 0-4, i.e., from no to profound disability, adding scores on 4 items gives the ‘total disability score’. Global disability score is calculated by adding the ‘total disability score’ and MI2Y score (months in two years – a score ranging between 1 and 4, depending on the number of months in the last two years the patient exhibited symptoms). Global disability score of O (i.e., 0%) corresponds to ‘no disability’, a score between 1-7 (i.e., 40 per cent corresponds to moderate to profound disability. The Rehabilitation Committee of Indian Psychiatric Society developed this scale13. It has been tested at various centres. The alpha value was 0.8682, indicating good internal consistency between the items. It has good criterion validity and at face value, the instrument appeared to be measuring the desired qualities. Criterion validity was established by comparing IDEAS with SAPD (Schedule for the Assessment of Psychiatric Disability) which has been standardized in India.
Students ‘t’ test was applied to compare the disability in patients with schizophrenia and OCD.
A total of 57 patients of (30 with schizophrenia and 27 with obsessive-compulsive disorder) were included in this study. Of the 30 patients of obsessivecompulsive disorder initially included, 3 patients were excluded as they were found to have conditions likely to cause disability per se (one had a seizure disorder, another had a history of intermittent excessive alcohol abuse, and the third one developed severe anxiety symptoms).
Majority of patients were males. Most of the patients were from rural background in schizophrenia group and majority were from urban background in obsessive-compulsive disorder group. Most of them were Hindus (Table I).
Mean age of patients suffering from schizophrenia was 35.7±9.79 yr and that of patients with OCD was 30.85±8.63 yr. Duration of illness (2-5 yr or >5 yr) showed no statistically significant effect on items of IDEAS and global disability score in patients with schizophrenia. However, there was comparable disability in both the groups. In patients with OCD, significantly higher mean score was seen in area of work (P5 yr than those with 2-5 yr (Table II).
When patients with schizophrenia and OCD with duration of illness between 2-5 yr and >5 yr were compared, statistically significant differences were seen in the areas of self-care, interpersonal activities, communication and understanding, work and global disability score. There was greater disability in each area in patients with schizophrenia (Table II).
Of the 30 patients with schizophrenia, 21 had moderate disability and 8 had severe disability, while majority of patients of obsessive compulsive disorder (18 of 27) had mild disability on IDEAS, only 9 had moderate disability.
Many patients with OCD were from urban background in our study. The poor representation of rural population may be due to the inability to understand this being an illness. It has been shown that obsessive-compulsive disorder produces a significant impact on daily living14,15.
Most of the patients with schizophrenia having duration of illness between 2-5 yr had moderate to severe disability. There was no increase in the disability with longer duration of illness. Hence, it could be possibly inferred that disabling potential of illnesses like schizophrenia unraveled itself to its full by 2 yr of active illness. The resulting disability, however, remained stable thereafter irrespective of the duration of illness. Marneros et al16, reported that schizophrenia caused persistent alterations in social life like social and occupational drift, premature retirement, and inability to achieve the expected social development.
In our study, there was more work impairment in patients with OCD with duration of illness more than 5 yr than in patients with duration of illness between 2-5 yr; this however, needs confirmation in a larger sample. The factors responsible for deterioration in the working ability of patients with obsessivecompulsive disorder need to be explored in further studies. The disability produced in areas of self-care, interpersonal activities and communication and understanding remained stable over the time. Koran et al17 reported that 22 per cent of OCD patients were unemployed, however, Khanna et al18 did not substantiate the same findings. Notably these two studies did not include the patients with duration of illness more than 2 yr.
When patients with schizophrenia and OCD were compared with matched duration of illness, significantly greater disability was seen in the patients with schizophrenia in the areas of self-care, interpersonal activities, communication and understanding, work and global disability score. This is in contrast to findings reported by Bobes et al19 who found greater level of disability in patients with obsessive-compulsive disorder than in schizophrenia in the area of social and occupational functioning. Other workers20,21 also reported that patients with OCD had greater disruption on their careers and relationships with family and friends. However, in these studies19″21, no attempt was made to match the patients on the basis of duration of illness.
Because of the disability caused in the patients with schizophrenia and obsessive-compulsive disorder, psychosocial rehabilitation for these patients should become a major component of treatment programme for this population. This was so even when patients with illness of mild severity (on Clinical Global Impression Scale) only were included in our study. It appears that the instrument IDEAS is sensitive enough to pick up disability even at mild severity of illness. However, results of our study should be interpreted with caution. This was a cross-sectional small sample study, based on exclusively hospital-based outpatient sample, and therefore, is not likely to be representative sample of patients in community. Moreover, the premorbid assessment using standardized instruments was not carried out. The relationship between disability and socio-demographic variables like family structure, family income etc., needs to be evaluated in further studies.
1. The World Health Report 2001: Mental health: new understanding, new hope. Geneva: World Health Organization; 2001.
2. Bystritsky A, Saxena S, Maindment K, Vapink T, Tarlow G, Rosen R. Quality of life changes among patient with obsessive- compulsive disorder in a partial hospitalization program. Psychiatr Serv 1999; 50 : 412-4.
3. Hollander E, Kwon JH, Stein DJ, Broatch J, Rowland CT, Himelein CA. Obsessive compulsive disorder: Overview and quality of life issues. J Clin Psychiatry 1996; 57 (Suppl 8): 3-6.
4. Lehman AF. Measures of quality of life among persons with severe and persistent mental disorders. Sac Psychiatry Psychiatr Epidemiol 1996; 31 : 78-88.
5. Ashok, MV. Follow-up study of chronic schizophrenic reffered to a Day Care Centre. M.D. Thesis. Bangalore: Bangalore University; 1989.
6. Sharma PSVN, Tripathi BM. Disability in manic dépressives and schizophrenics: a comparison using the WHO disability assessment schedule. NIMHANS J 1986; 4: 7-17.
7. Chandrashekhar CR, Isaac MK, Kapur RL, Parathasarathy R. Management of priority mental disorders in the community. Indian J Psychiatry 1981; 23 : 174-80.
8. Ranga Rao NVSS. Comparative study of disability and family burden in rural and urban areas. M.D. Thesis. Bangalore: Bangalore University; 1988.
9. Multi-centred collaborative study of factors associated with course and outcome of schizophrenia. New Delhi: Indian Council of Medical Research; 1988.
10. Thara R, Rajkumar S. Drug compliance and disability in schizophrenia. Indian J Psychol Med 1991; 14 : 81-4.
11. Thara R, Joseph AA. Gender difference in symptoms and course of schizophrenia. Indian J Psychiatry 1995; 37 : 124-8.
12. The ICD-10 classification of mental and behavioural disorders- Diagnostic criteria for research. Geneva: World Health Organization; 1993.
13. Clinical global impression, ECDEU assessment manual for psychopharmacology, Guy W, editor. Rockville, MD: US Department of Health, Education & Welfare, 1976, DHEW Publication No.(ADM) 76-338.
14. Hollander E. Treatment of obsessive-compulsive spectrum disorders with SSRIs. Br J Psychiatry 1998; 173 (Suppl): 7-12.
15. Stein DJ, Roberts M, Hollander E, Rowland C, Serebro P. Quality of life and pharmaco-economic aspects of obsessive compulsive disorder. A South African survey. S Afr Med J 1996; 36 (Suppl 12): 1579, 1582-5.
16. Marneros A, Deister A, Rohde A. Psychopathological and social status of patients with affective, schizophrenic and schizoaffective disorders after long-term course. Acta Psychiatric Scand 1990; 82 : 352-8.
17. Koran LM, Thienemann ML, Davenport R. Quality of life for patients with obsessive-compulsive disorder. Am J Psychiatry 1996; 153 : 783-8.
18. Khanna S, Rajendra PN, Channabasavanna SM. Social adjustment in obsessive compulsive disorder. Int J Soc Psychiatry 1988; 34 : 118-22.
19. Bobes J, Gonzalez MP, Bascaran MT, Arango C, Saiz PA, Bousonon M. Quality of life and disability in patients with obsessive compulsive disorder. Eur Psychiatry 2001; 16 : 239-45.
20. Gallup Organization. A Gallup study of obsessivecompulsive disorder sufferers. Princeton NJ: Gallup Organizaiton; 1990.
21. Hollander E. Obsessive compulsive disorder: The hidden epidemic. J Clin Psychiatry 1997; 58 (Suppl 8): 3-6.
Indra Mohan, Rajul Tandon, Harish Kalra & J.K.Trivedi
Department of Psychiatry, King George Medical University, Lucknow, India
Received September 10, 2003
Reprint requests: Dr J.K. Trivedi, Professor, Department of Psychiatry, King George Medical University Lucknow 226003, India
Copyright Indian Council of Medical Research Jun 2005
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