180 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)E CAMDEN SCHIZOPH

AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERSOFINPATIENTSWITHSCHIZOPHRENIAININDIA

A.JAGANNATHAN,J.THIRTHALLI,A.HAMZA,V.R.HARIPRASAD, H.R.NAGENDRA&B.N.GANGADHAR

ABSTRACT

Aim: To explore the needs of caregivers of inpatients with schizophrenia in India.Material: Thirty caregivers of inpatients with schizophrenia participated in five focus group discussions (FGD), where the needs of the caregivers were discussed. The FGDs were recorded, transcribed and similar needs were grouped and ranked according to their order of importance. Discussion: The main needs that emerged were regarding: managing the behaviour of patients; managing social-vocational problems of patients; health issues of caregivers; education about schizophrenia; rehabilitation; and managing sexual and marital problems of patients. Conclusion: This study has identified additional needs of caregivers from those found in other studies.

Key words: needs, caregivers, schizophrenia, focus group discussion, qualitative analysis

INTRODUCTION

Theimportanceoftheroleoffamilycaregiversinthetreatmentofapersonwithmentalillnesscannotbeoveremphasized.Familycaregiversprovideconsiderablesupport totheir illrelativesevenwhiletheyexperiencesignificantburden(Leff,1994).InasurveyconductedbyConsumerHealthSciences(CHS)andtheNationalMentalHealthAssociation(NMHA),onethirdofthe1,328familycaregiverssurveyedsaidthattheemotionalandbehaviouralsymptomsoftheillnesscausedthemextremehardshipandwasaconstantsourceofanxiety(ConsumerHealthSciences,2008).Caregiverswhoarein‘highcontact’withthepatientintheirdailylifeoftenfacethehighestburden(Winefield&Harvey,1994).Familycopingstrategiesaccountedforasubstantialproportionofthevarianceobservedinobjectiveandsubjectiveburdenrespectivelyamongcaregiversofpersonswithschizophrenia(Maglianoet al.,1998).Thishighlightsthefactthatstudyingtheneedsoffamilycaregiversofpatientswithseverementaldisordersisimportantfromapublichealthperspective.

InIndia,themajorityofthepeoplewithschizophreniastaywiththeirfamilies(Tharaet al.,1998;Murthy,2006).TherehavebeennosystematicscientificIndianstudiestoassesstheneedsofcaregivers;however,severaldifferentopinionshavebeenexpressed.Someoftheneedsopinedaretheneedforawarenessaboutthenatureandoutcomeofmentalillnessesinthecommunity,

InternationalJournalofSocialPsychiatry.©TheAuthor(s),2011.Reprintsandpermissions:http://www.sagepub.co.uk/journalsPermissions.navVol57(2):180–194DOI:10.1177/0020764009347334

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 181

theneedforprimarypsychiatricandotherprofessionaltreatment,andpsychosocialrehabilitation(Goswami,2006;Janardhan,2006).Caregiversofinpatientsreportexperiencingasignificantlyhigherburdenthancaregiversofoutpatients.Unmetneedsofthepatientshavealsobeenfoundtobesignificantlyrelatedtocaregiverburden(Clearyet al.,2005).Meetingtheseneedswouldhelptoenhancetheleveloffunctioningofthepatient(Solomon&Draine,1994)andtodecreasetheemotionalproblemsoffamilymembers(Johnson,1994).

Familymembersofapatientwithchronicschizophreniahavemultipleneeds.Themajorcon-cernsandsupportneedsofindividualswhoassumethisstressfulroleincludeobtainingsupport,reducingriskstotheirownwell-being,andpromotingthewell-beingofthementallyill(Chafetz&Barnes,1989).Theyoftenexpresstheneedformoresupportandcomplainofnothavingenoughopportunities to relieve the burden imposed on them (Angermeyer et al., 2000). Educationalneedsincludegaininginformationaboutearlywarningsignsoftheillnessandrelapse,theeffectsofmedicationandwaysofcopingwiththepatient’sbizarreandassaultivebehaviour(Chien&Norman,2003).Oftenfamilymemberslivingwithillpersonsarelessawareofthepsychiatricnatureoftheillness(Padmavathiet al.,1998).Thusitisnecessarytounderstandtheneedsoffamiliesofpersonswithmentalillnessandtodevelopspecificinterventionstomeettheminordertohelpreducecaregiverburden(Clearyet al.,2006;Murthy,2006).

ThepresentstudywasconductedinordertoassesstheneedsofthecaregiversofschizophrenicpatientsinIndia.Indiaspendsamere0.83%ofitstotalhealthbudgetonmentalhealthcomparedtoEnglandandWaleswhichspends13.8%(WHO,2001);thus,theextenttowhichtheneedsofcaregiverswillbemetinIndiaislikelytobedifferent.Furthermore,giventhedifferencesinthesocio-culturalmilieu,theresultsofthestudiesdoneinotherculturesmaynotberelevantinanIndiancontext.

Further, studiesusing scales to assess caregiverneedshave the limitationof forcing the re-spondentstoanswerfromalist.Forinstance,studieseitherfocusonspecificneedssuchasedu-cationalneeds(Chien&Norman,2003)orongroupsofneedssuchascounsellingandsupportservices,educationandfinancialentitlements(Wancataet al.,2006;Barrowcloughet al.,1998).Weusedaqualitativeapproachtoassesstheneedsofcaregiversforseveralreasons:(a)thisapproachisusefulintappingabroaderrangeofneedsthatarespecifictothecontextinwhichitisused;(b)studyingtheneedsofcaregiversinvolvesprobingofsensitive,emotionalandpersonalthemesofneeds,whichismoresuitedtoaqualitativeapproach(Hidayet al.,2002;Padget,1998);and(c) qualitative studies are especially helpful when one intends to generate impressions and todevelopassessmentscales,programmesorservices(Stewartet al.,2007).

METHOD

SampleThe participants were 30 caregivers of inpatients with schizophrenia at the National InstituteofMentalHealthandNeuroSciences(NIMHANS)inBangalore,India–atertiarycarecentre.NIMHANShasa900-bedteachinghospitalwithtrainingandresearchfacilitiesinpsychiatryandotherneurosciences.InApril2008,caregiversofallinpatientswithschizophreniawerescreened.Intotal,59patientswithadiagnosisofschizophreniawereadmittedtothehospitalduringthisperiod.CaregiversofpatientswithadiagnosisofschizophreniawereincludedinthestudyiftheyweretocontinuetoprovidecareforthemfollowingdischargeandiftheyspokeKannada,Tamil,EnglishorHindi.Caregiverswithpsychiatricorneurologicaldisordersandthosecaringforanother

182 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

relativewithpsychiatricillnesswereexcluded.Thirtyeightcaregiverswhofulfilledtheseinclusionandexclusioncriteriawereapproached.Of these38caregivers,30consented toparticipate inthestudy.Theseincludedfamiliesfromdifferentsocioeconomicbackgrounds,differentstatesofIndiaandfromdifferentcarerroles.The30caregivers thusrecruitedparticipatedinfivefocusgroupdiscussions(FGDs),withapproximatelysixcaregiversparticipatingineachoftheFGDs.ThesociodemographicdataofthecaregiverswhoparticipatedintheFGDsandaprofileoftheirillrelativeswerecompiled(Table1).

Focus group discussion Fromtherangeofqualitativeresearchmethodsavailable,theFGDmethodwasselected(vis-à-visindividualinterviews),asitislesstime-consuming,economicalandhasthebenefitsofgroupprocesses(Stewartet al.,2007).ThediscussionsfollowedtherecommendationsofStewartet al.(2007)–theyinvolvedsixtoeightindividualswhodiscussedtheresearchquestion‘Whataretheneedsoffamilycaregiversofinpatientswithschizophrenia?’forapproximately1.5–2.5hours.TheFGDwasconductedunderthedirectionofamoderator(AJ/HVR)whopromotedinteractionsandensuredthatthediscussionsremainedfocusedonthetopicofinterest.

ScriptA standardized script for conducting the FGD was developed on the basis of the aims of thestudy,literaturereviewanddiscussionwithfourexperiencedfocusgroupresearchers.Thescriptfollowedasemi-structuredformatusingopen-endedquestionsinaface-to-face‘conversational’styleratherthanaformalquestion/answerformat.(Thescriptisavailablefromtheauthorsonrequest.)Althoughthegroupdiscussionscriptwasflexibleinnature,somedirectionwasgivenwhenthefocuswaslostandprobeswereusedwhennecessary.Thescriptincludeddiscussionaboutthefeltneedsofthecaregiversincaringfortheirrelativewithschizophrenia,andthegroupingandrankingofsimilarneedsaccordingtotheirorderofimportance.

ProcedureThestudywasreviewedandapprovedbytheInstitute’sethicscommittee.Writteninformedconsentofthefamilycaregiverswasobtainedtoparticipateinthestudyandasociodemographicsheetelicitinginformationontheirage,occupation,monthlyincome,maritalstatus,patientvariablesandfamilyconstellationwascompleted.EachFGDwasvideo-recordedandwasfacilitatedbytheresearcher(psychiatricsocialworker)andaco-facilitator.Theresearcherfacilitatedthegroupprocessandtheco-facilitatorhelpedinrecordingtheobservationsofthegroupsession(audio/videoandbytakingdownnotes).

TheFGDinvolvedtheresearcheraskingthecaregiverstolisttheirneeds(Appendix),groupthelistofneedsintomainthemes,operationallydefinethethemesandranktheminorderofimportance.Asthemethodologyoffreelistingofneedswasused,alltheneedsexpressedbythecaregiverswerenoted.AcrossallfiveFGDs,theneedsofcaregiverswerefoundtobelargelycomparable.Thus,noneedsweredeletedfromthelistandallneedswereaccommodatedintoeitheroneofthecategories/themes.Incaseofdifferencesofopinionwithinthegroupaboutthegroupingandrankingofsimilarneeds,furtherdiscussionandcross-clarification(iteration)wasconductedamongthememberswhodifferedintheiropiniontillaconsensuswasreached.Ingroupswhereconsensuscouldnotbereached,thethemesweregivensimilarranking(e.g.inFGD-2,thethemesofhealthofcaregivers,rehabilitationoptionsandmanagingsocial/behaviouralproblemsofpatientsweregivensimilarranking).

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 183

Tabl

e 1

Soci

odem

ogra

phic

dat

a of

car

egiv

ers

and

pati

ents

Car

egiv

ers

(n =

30)

Pat

ient

s (n

= 2

9)**

Var

iabl

en

(%)

mea

n (S

D)

Var

iabl

en

(%)

mea

n (S

D)

Var

iabl

en

(%)

mea

n (S

D)

Age

of t

he c

areg

iver

(ye

ars)

*

50.6

(13

.4)

Edu

cati

on

(yea

rs)*

10

.2(

6.4)

Age

of p

atie

nt (

year

s)*

31

(

8.7)

Gen

der

m

ale

fe

mal

e

13

(43.

3)

17

(56

.7)

Mar

ital

sta

tus

si

ngle

m

arri

ed

wid

owed

3

(10)

25

(8

3.3)

2

(6.7

)

Gen

der

m

ale

fe

mal

e

17

(58

.6)

12

(

41.4

)

Rel

igio

n

Hin

du

Chr

istia

n

27

(90

)

3(

10)

Fam

ily

type

nu

clea

rfa

mily

jo

intf

amily

23

(7

6.7)

7

(23

.3)

Edu

cati

on in

yea

rs*

11

.38

(4.

9)

Eco

nom

ic s

tatu

s

low

m

iddl

e

high

13

(

43.3

)

6(

20)

11

(

36.7

)

Rel

atio

nshi

p w

ith

the

pati

ent

pa

rent

si

blin

g

othe

rre

latio

ns

spou

se

21

(7

0)

4(

13.3

)

3(

10)

2

(6.

7)

Dur

atio

n of

the

illn

ess*

10

3.60

(59

.5)

Occ

upat

ion

un

empl

oyed

da

ily-w

age

labo

urer

pr

ofes

sion

al

hous

ewif

e

retir

ed

stud

ent

1

(3.

3)

8(

26.7

)

4(

13.3

)

8(

26.7

)

8(2

6.7)

1

(3.

3)

Com

orbi

d ph

ysic

al il

lnes

s

nil

di

abet

esm

ellit

us

hype

rten

sion

ot

hers

20

(6

6.7)

3

(10

)

4(

13.3

)

3(

10)

Type

of s

chiz

ophr

enia

pa

rano

id

hebe

phre

nic

ca

tato

nic

un

diff

eren

tiate

d

schi

zoaf

fect

ive

19

(6

5.5)

2

(6.9

)

1(3

.4)

5

(17.

2)

2(6

.9)

*Mea

n(S

D),

**

Two

care

give

rsr

epre

sent

edo

nep

atie

ntin

one

of

the

FGD

s.

184 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

Data analysis Thefirstlevelofdataanalysiswasdoneduringeachofthefocusgroupsessions.Theresearchermadealistofneedsduringthediscussion.Thegroup(caregivers)thendividedtheseneedsintothemesandsub-themesandrankedthemaccordingtotheirimportance.Followingthetechniqueofiteration,thegroupwentoverthesethemesandrankingsseveraltimesbeforefinalizingthem.IneachFGDthemostimportanttheme(basedongroupingandrankingatleveloneandtwoofdatamaking)wasgiventhehighestscore(equaltothenumberofthemeslisted)andtheleastimportantthemewasgiventheascoreof1.IftwoormorethemesweredeemedashavingequalimportanceduringtheFGD,thensuchthemesweregivensimilarscores.IfathemewasnotrepresentedinaparticularFGD,itwasgivenascoreof0inthatFGD.

EachFGDwastranscribedandfurtherdatamakingandanalysiswasconductedbytheresearcher(secondlevelofdatamaking).Basedonthefirstlevelofdatamaking,theresearcherreviewedthelistingofthemesandwherevertwoorthreethemesseemedtorepresentacommontheme,theyweregroupedunderanappropriatetheme.Thethemethusgeneratedwasgivenascorebyaveragingthescoresfromthefirstlevelofdatamaking.Forexample,inFGD-5,outofthesixthemesidentifiedbythecaregivers,themesof‘educationalneeds’(score=6)and‘informationonmanagementofsideeffectsofmedicines’(score=4)weregroupedbytheresearcherasonemainthemeof‘educationneeds’andgivenascoreof5.

Theresearcherthencheckedtheremainingtextforleftoverlistsofneedsandputthemunderthemostappropriatetheme.ThescoresforeachthemeacrossthefiveFGDsweretotalled.Thefinalrankingofthethemescorrespondedtothesetotals;thethemewithhighesttotalscorewasrankedasthemostimportantneed(Table2).

TheneedsundereachthemeacrossthefiveFGDswerelisted.Afinallistofthemesandneedsunder each theme was tabulated for analysis.As the sample size in each FGD was small, nocomputer-assistedsoftwarepackagewasusedforthedataanalysis.Computersoftwarewouldhavebeenappropriateif30individualinterviewshadbeenconductedinsteadofsixgroups.

Duringtheentirestudyperiod,theillrelativecontinuedtoreceivetheroutinetreatmentprescribedbythedoctorsatNIMHANS.ThetreatingdoctorswereconsultedandtheirapprovaltoconducttheFGDwasobtained.

RESULTS

ThemainneedsthatemergedfromtheanalysisoftheFGDsaredescribedinTable2.

I: Managing illness behaviourTheareasinwhichthecaregiversneededhelptomanagetheillnessbehaviouroftheirrelativewere:managingtheirnon-compliancewithmedication;uncooperativebehaviour;aggressiveanddemandingbehaviour;dealingwiththeirillnesssymptoms(hallucinations/delusions,wandering,insomnia, spending behaviour, reduced food intake); increased substance use; handling theirunpredictablebehaviour;lackofinterestinself-care;concentrationproblems;andlackofdailyroutine.Thefollowingquotesofthecaregiversdepicttheproblemstheyfacedinmanagingtheillnessbehaviouroftheirrelative.

‘Evenwhenthefamilymembersadviseorrequest,mybrothersays,“NoIamnotthepatient;youhaveaproblem,sowhyshouldItakethemedication?”’(MrS.M.(47years),FGD-2)

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 185

‘Ifsomebodyvisitsus,andwearetalking,mydaughterfeelsasifwearetalkingabouther.Whatevertopicwetalkabout,shetellsthatwearetalkingabouther.NextwhenIgiveherfood,shesuspectsthatIhavemixedpoisonorfaecesinthefood.’(MrsJ.(36years),FGD-3)

‘Suddenlymydaughtergetsangry,veryangrytoanextentthatshedoesnotgetpacifieduntilandunlessshehurtssomeone,evenifitweremysonormyself.’(MrsJ.(36years),FGD-3)

‘Mydaughterdoesnotdoanything.Ihavetodoeverythingforher…fromcombingherhair,washingherclothes.Ihavetoscrubandbatheheralso.’(MrsJ.(36years),FGD-3)

II: Managing social-vocational problems Caregiversdiscussedvariousareaswheretheyneededprofessionalhelpinmanagingthesocial-vocational problems of their ill relative.These were: dealing with patient’s lack of interest insocialization/notgoingoutofthehouse;relationshipproblems;uninhibitedbehaviour;anddifficultyininitiatingandmaintainingactivities/job.Thefollowingquotesofthecaregiversthrowlightonthesocial-vocationalproblems.

‘Mysonisalwaysinthehome.Henevergoesout.Hedoesnotmixevenwithourrelativesorworkers…hefindsitdifficulttogetoutoftheroom.’(MrsB.M.(60years),FGD-2)

‘Mysoncomesoutofthebathroomattimeswithoutwearinghisclothes.Evenwhenwetellhim,hedoesnotlisten.Itbecomesverydifficultifthereareguestsathome.’(MrM.S.(45years),FGD-3)

‘Iwouldwantmysontogotoajob.Hehasforgottenaboutgoingforthejobcompletely.Hedoesnothaveamindtogoforajob.(MrM.R.(65years),FGD-4)

Mysonhaschangedsevencompanies.Innocompanyhehasworkedformorethantwotothreedays…Hegetsajobeasily.Fourappointmentsareinhand.Butafterjoining,hecannotmaintainthejob.’(MrR.(68years),FGD-4)

Table 2 Ranking, rating and percentage of importance of themes across five FGDs

Rank order Theme FGD-1 FGD-2 FGD-3 FGD-4 FGD-5 Total %*

I Managingillnessbehaviourofpatients

4 6 6 3 4 23 27.7

II Managingsocial-vocationalproblemsofpatients

3 4 5 2 3 17 20.5

III Healthofcaregivers 1 4 4 4 2 15 18.1

IV Educationaboutillness 5 1 1 1 5 13 15.7

V Rehabilitation 2 5 3 0 1 11 13.2

VI Managingsexualandmaritalproblemsofpatient

0 2 2 0 0 4 4.8

*Percentageoftotalneedsscorerepresentedbythethemes.Totalneedsscore=(23+17+15+13+11+4)=83.

186 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

III: Health needs of caregiversCaregivershadanumberofhealthneeds.Theyrequiredhelpin:managingtheiremotions(anger,depression, fear); handling their stress; taking decisions; dealing with lack of social support;reducedpersonallife;andbalancingworkandpatientcare.Thefollowingquotesofthecaregiversexemplifytheirhealthneeds.

‘Iamalwaysworriedaboutthepossibilityofsucheventshappeningathome[violentoutburstofthepatient].Sowecontinuouslysufferfromtensionandsadness.’(MrM.S.(45years),FGD-3)

‘Nofacility,noneighbours,norelativesorfriendscametohelpuswhenthepatientwasviolent.Wewerehelplessanddidnotknowwhattodo.[MrC.R.isoverwhelmedandstartscrying.]EvenifIcalledfortheambulanceatourplace,theydonotcome.Thuswestartgettingnegativefeelingslikeanger.Weneedtoknowhowtocontrolthesefeelings.’(MrC.R.(25years),FGD-2)

‘Forthepast10years[sincemybrother’sillnessstarted],theconceptofmypersonallifeiscompletelyzero.IamnowadjustedtothislifeandIstoppedmystudies.Inowtakecareofmybrotherfull-timeasmyparentsareaged.’(MrS.(33years),FGD-4)

IV: EducationEducationneedsofthecaregiversincluded:educationabouttheillness;informationonmedication/sideeffects/emergencymedicine(sedatives);informationonavailableconcessions/benefitsofferedbythegovernment;andinformationonhowtodealwithstigma.Thefollowingquotesdepictthecaregiverneedsforeducation.

‘Themedicineshavesomanysideeffects.Thedoctordoesnottellusthatthismedicinewillgivesideeffects.’(MrI.K.(60years),FGD-1)

‘Ineventof thepatientbecomingveryviolent andnot responding tous, if there is anypillwhichcanbegiventohimatthattimeandifhesleeps…[anothergroupmembercontinues]…one liquid…ifbyaddinga fewdrops in food,hewillbeok,wecan thenbringhim to thehospital.Butwedon’tknowwhattogiveandwhatnottogive[pill].Weneededucationonthat.’(MrS.M.(47years)andMrsB.M.(60years),FGD-2)

‘Forthepatientandcaregiversweshouldknowabouttheconcessionsavailablefromthegov-ernment.Forotherpeople[ofotherdisorders]theygetreimbursedfortheirtreatment.Wearenotgettinganymoneyfromanywhereandwehavetospendalotofmoney.’(MrsB.M.(60years),FGD-2)

‘Thereisalotofstigmaaboutthisillness…alotofmisconceptionsaboutmentallyillpatients.Theydonotunderstandwhattypeofillnessthisis,whatistheproblem.Soeducatingsocietyisimportant.’(MrC.R.(25years),FGD-2)

V: Rehabilitation

Allcaregiverscitedtheserehabilitationneeds:knowingaboutfinancialandrehabilitationoptions;localsupportgroupsandhelplineservices;office/workbenefitsforcaregivers;andlocalreferralsystems.Thefollowingquotesdepicttherehabilitationneedsofthecaregivers.

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 187

‘Psychiatricpatientshaveveryfewrehabilitationoptions…patientswhoarewell…around70%ofthem,ifsomesmalljobscanbeprovidedforthem…smallencouragementcanbegiventothembythegovernment,itwouldbehelpful.’(MrI.K.(60years),FGD-1)

‘Developmentoflocalsupportgroupsincity/hometownslikepalliativecaregroupsforcancerpatientswillbeagreatrelieftoallpeople,whereverweare.’(MrsM.(52years),FGD-2)

‘Atleastinmedicalcolleges,connectedwiththisissueahelplinecanbeopened.Thegovernmentcandothis.’(MrsB.M.(60years),FGD-2)

‘Ifwearegovernmentemployees,atanytime,wedonotgetleaveandwecangettransferred.EvenwhenItriedtoconvincemysuperiorsthatIhadtotakecareofthreementallyillpersonsat home [officers] theydidnot listen.Theyprocessed my transfer order.So if certain rulesandregulations togive leave tousasacaregiverofapatientaremade, itwouldbeuseful.’(MrC.R.(25years),FGD-2)

‘Asmallcentreshouldbemadeavailable[developed]inourstate,inanyofthecitiesorinanyplaceinthestate–withonedoctor.IfpatientdoesnotwanttocometoNIMAHNS,wedonotknowwheretotakehim.Ineverycrisissituationwecannotcomeoverhere[toNIMHANS].Thereneedstobealocalreferralsystem.’(MrsB.M.(60years),FGD-2)

VI: Managing the sexual and marital problems of patientsCaregiversofpersonswithmentalillnessfacedanumberofproblemsrelatedtothesexualandmaritalissuesofthepatient.Theyneededhelpindealingwithissuessuchas:whethertogetthepatientmarried;problemsingettingpatientmarried;problemsinmaintainingthepatient’smarriagepost-illness(separation/divorceissues);andproblemsofthepatientrelatedtosexualactivities/maritaldiscord.Thefollowingquotesofcaregiversexemplifysomeoftheabovethemes.

‘Wehaveseenafewgirlsformyson’smarriage.Butallthepartieswegotosee,somebodyinourvillagewouldhavealreadytoldthemthatheisnotmentallywellandthealliancewouldberejected.’(MrsB.M.(60years),FGD-2)

‘Mybrotherismarriedbuthiswifedoesnotstaywithhim.Hehasachildandhiswifehasputthechildinahostel.Thisisbecausefrom1999heisgettingtreatmentfromNIMHANSandhewasnotcured.Afterhegoesbackhome,withinafewdaysthesymptomsrelapse.Sohiswife’sfatherandmotherhaveadvisedhernottogobacktoherhusband.Wedonotknowhowtodealwiththissituation.’(MrS.M.(47years),FGD-2)

DISCUSSION

Theneedsofthecaregiversareextensiveandvaryacrosscultures.Anin-depthassessmentandanalysis is of paramount importance in order to develop programmes to cater to the needs ofcaregiversinaculturalcontext.ThepresentstudyexploredtheneedsofcaregiversofinpatientswithschizophreniainIndia.ThethreemainneedsthatemergedfromtheanalysisoftheFGDs,

188 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

were (in order of importance) help in: (1) managing the illness behaviour of the patients;(2) managing social-vocational problems of patients; and (3) health needs of the caregivers.Somepublishedstudieshavefocusedonspecificneedssuchasrehabilitationand/oreducation(Chien&Norman,2003;Winefield&Harvey,1994).Mostotherstudieshaveusedastandardizedneedsquestionnairetoassesscaregiverneeds.TheCamberwellAssessmentofNeed(CAN),oneofthemostwidelyused,ismoreoftenusedwithpersonswhoareincontactwithmentalhealthservicesandarereceivinginpatient,outpatientorday-patientcare(Phelanet al.,1995).TheCarer’sNeedsAssessment(CNA)andtheRelativesCardinalNeedsAssessment(RCNS),ontheotherhand,focusoncaregivers’educational,financial,socialandinterpersonal,professionalsupportandhealthneeds(Wancataet al.,2006;Barrowcloughet al.,1998).

Assessingtheneedsthroughthemethodofaquestionnairecouldlimittherangeofexpressionoftheneedsofcaregivers.Thequalitativeassessmentmethodusedinthisstudyhasbeenusefulinfindingin-depthrequirementsofcaregiversineachneedarea–anadditionalcomprehensiveresult,differentfromthatofotherstudies.Forexample,under‘healthneeds’variouscaregivers’requirementswerecoveredsuchastheneedtomanagestressandemotions,theneedtomaintainbalancebetweencaregivingandpersonallife/workandtheneedtoknowhowtotakedecisionsinstressfulsituations.

Theresultsofthecurrentstudycouldalsobeinterpretedintermsofthesample–howneedsofcaregiversofinpatients(whohadrecentlybecomeillorwhoseillnesshadexacerbated)coulddifferfromthoseofcaregiversofoutpatients(Clearyet al.,2006).Thecaregiverswhoparticipatedinthisstudyweremorepatient-focusedratherthancarer-focused.Thisreflectsnotjustthealtruisticpreoccupationsoffocusgroupparticipants,butalsothefactthatallthesecaregiversweretakingcareofpatientswhowerecurrentlysymptomaticandrequiredimmediatehospitalizationfortheirsymptomcontrol.Managing the symptomsof thepatientswas always consideredas themostimportantpriority.Thereweredifferencesinopinionbetweencaregiversinsomegroupsaboutwhetherrehabilitation,educationortheirhealthneedswasthenextimportantneed.Thehomogeneityofthesample(allcaregiversofinpatientswithschizophrenia)couldbeareasonforallthecaregivershavingsimilarprioritiesintakingcareoftheirpatient.

Furtherculturalfactors,suchasstrongfamilysystems,couldhaveabearingontheresultsofthestudy.InIndiathepatientisalwaysaccompaniedbythefamilymember(whoisthecaregiver)ascomparedtoothercountrieswherecaregiversarenotnecessarilyfamilymembers(Tharaet al.,1998;Leff,1994).

ThesociodemographicprofileofthecaregiversinthisstudyisconsistentwiththatofearlierstudiesonIndiancaregiversofpersonswithschizophrenia(Srinivasan,2006;Murthy,2007). Allcaregiverswerefamilymembers.Mostofthemwereparents,especiallymotherswhohadalowerincomeandwereintolateadulthoodoroldage.Itmayalsobenotedthattheproportionofpatientslivinginnuclearfamiliesinthisstudy(76.7%)iscomparabletothatofthegeneralpopulationofIndia(70.4%;OfficeoftheRegistrarGeneralandCensusCommissioner,India,2001).

Caregiversinthestudyreportedthattheirprimaryneedwashelpinmanagingthesymptomsofthepatient.Duetolackofknowledge,fearandstigmaassociatedwithmentalillness,caregiversoftenfoundthemselvesatalossastohowtodothis(Gandonet al.,2008).Dealingwiththesocial-vocationalproblemsofthepatient(secondneed),wasanotherareaofconcernforthecaregivers.Someexpressedmoreconcernabout‘negative’symptomsofschizophrenia(e.g.socialwithdrawal)

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 189

thanaboutpositiveones(e.g.hallucinations)(Northet al.,1998).Furthercaregiversseemedtounderstandthattheyhadtotakecareoftheirownhealth(thirdneed)inordertobettercareforthepatient.

Apartfromtheabovethreemainneeds,caregiversalsoperceivedtheneedforeducation(fourthneed)asimportant,asitwouldhelpreducestigmainsocietyaboutmentalillness(Murthy,2006).Caregiversrequiredinformationnotonlyabouttheillness,butalsoaboutmedication/sideeffects/emergency medication (sedatives) and about the available concessions/benefits offered by thegovernment(Clearyet al.,2005;Chien&Norman,2003).TheconceptofstigmawasdiscussedbythecaregiverswhoparticipatedinFGD-2inthecontextof‘educatingthesocietytominimizethestigmainsociety’.Thus,theissuewasconsideredunderthecategoryofeducationasthefocuswasoneducatingsociety–clearingmisconceptions,noteradicatingstigma.Rehabilitation(fifthneed)wasexpressedasimportantbythecaregivers;asmostofthecaregiversstayedinnuclearfamilies, they requiredhelp in the formoffinancialand legalconcessions,office/work-relatedbenefitsforcaregivers,rehabilitationcentres/daycarenearhome,helplineservicesandlocalsupportgroups.Apartfromtheavailabilityoftheseservices,theyalsoneededinformationaboutthemandhelpinaccessingtheseservices(Clearyet al.,2005).Thesixthneedwassexualandmaritalprob-lemsandknowinghowtodealwiththem.ThiswasasignificantneedintheIndiancontextasmarriageandprocreationareconsidered tobe important stages in the Indian family lifecycle(Madan,1987).Caregiverswanted toknowwhether toget theirpatientmarried; thestigmaofgettingthepatientmarriedwithamentalillness;andhowtodealwithdifficultiespost-marriagelikerelapseofsymptomsandmaritaldiscord.

Inacountrywherethereareveryfewpsychiatrists,thefocusoftreatmentismoreonsymptomcure.EveninatertiarymultidisciplinarycentrelikeNIMHANS,thefocusisoftenonneedsotherthanthehealthneedsofthecaregivers.Estimatesshowthat50%ofpatientsapproachNIMHANSasaprimarycarecentre(Kareet al.,2008).Thismakesitdifficulttodealwithalltheneedsofthepatientsandcaregivers.Needslikerehabilitation,educationandsexualconcernsofthepatientcanbemanagedathospitallevel.However,thehealthneedsofcaregiversthatareequallyimportantareoftennottakenaspartofthepatients’treatmentprocessatthehospital.Asitsaim,thisstudywillattempttodevelopastructuredinterventionprogrammebasedontheholisticcoverageofalltheneedsofthefamilycaregivers.

Certainmethodologicalissuesofthisstudyneedtobementioned.ThemethodofFGDhascertaininherentlimitationssuchasthegroupmembers’responsesarenotindependentofoneanother,whichrestrictsthegeneralizabilityoftheresults(Stewartet al.,2007).Someofthememberswerehesitanttotalkinagroupsituation–especiallywhensharingsensitiveissues.Caregiversmayhaveexpressedotherneedsiftheyhadbeeninterviewedindividually.Individualinterviewscouldthushaveaddedconsiderablestrengthtotheresultsofthestudy.Anyinterpretationoftheresultsneedstobedonekeepinginmindtheexclusionofcarerswhowerenotcomfortablewithagroupsituation.Further,theresultsobtainedfromtheFGDmayhavebeenbiasedbyaverydominantoropinionatedmember.Futurestudiescouldexaminethevalidityofthehierarchyofneedsbypresentingthefindingsofthisstudytoanotherfocusgroupofcarers.

To counter some of these methodological limitations, informed consent of the members toparticipateinafocusgroupwastakenbeforethestartoftheFGD.Thosememberswhowerenotcomfortablewithtalkinginagroupsituationwerenotchosenforthestudy.Further,themoderatorbiaswasminimizedbyaskingthegroupmembersthemselvestolistandranktheneedswithoutconsultingthemoderator.

190 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

All family caregivers who attended the FGDs emphatically stated that they required helpin managing all their needs and expressed their willingness to participate in any training thataddressedthis.

CONCLUSIONS

ThisstudyisoneofthefirstscientificallyresearchedqualitativeneedsassessmentstudiesofthecaregiversofinpatientswithschizophreniainIndia.Further,thisstudygivesanholisticviewoftheneedsofcaregiverswiththelistofthemesandsub-themesthatneedtobeconsideredforanyfutureaction.Itputssignificantemphasisonhealthneedsofthecaregivers(thirdimportanttheme),whichhasoftenbeenignoredinotherinterventions.Itmustbenotedthateachpatientmayhavemorethanonecaregiverandhelpofanykindtomanagetheirhealthneedsmayhavepublichealthsignificance.

Finally,thesefindingsarehighlyindicativeandfuturestudiescouldtesttheresultsinalargerquantitativesampletoreconfirmthevalidity,reliabilityandgeneralizabilityoftheresults.Ifvalidated,itwouldenablethedevelopmentofanyprogrammedevelopedforIndianfamilycaregiversbasedontheneedsassessment.Asanoutcomeofthisstudy,theresearchersplantodevelopapsychosocialandyogaprogrammeforfamilycaregiversofinpatientswithschizophreniainIndia.

ACKNOWLEDGEMENTS

TheresearcherswouldliketothankDrShekharP.Seshadri,DrPrabhaS.Chandra,DrJayashreeRamakrishnanandDrK.Subbakrishnafortheirvaluableinput,whichhelpedinthedevelopmentofthefocusgroupscript.

REFERENCES

Angermeyer,M.C.,DiazRuizdeZarate,J.&Matschinger,H.(2000)Informationandsupportneedsofthefamilyofpsychiatricpatients.Gesundheitswesen,62(10),483–486.

Barrowclough, C., Marshall, M., Lockwood,A., Quinn, J. & Sellwood,W. (1998)Assessing relatives’ needsfor psychosocial interventions in schizophrenia:A relatives’ versionofCardinalNeedsSchedule (RCNS).Psychological Medicine,28,531–542.

Chafetz,L.&Barnes,L.(1989)Issuesinpsychiatriccaregiving.Archives Psychiatric Nursing,3(2),61–68.Chien,W.T.&Norman, I. (2003)Educationalneedsof familiescaring forChinesepatientswithschizophrenia.

Journal of Advanced Nursing,44(5),490–498.Cleary,M.,Freeman,A.,Hunt,G.E.&Walter,G.(2005)Whatpatientsandcarerswanttoknow:Anexploration

of informationandresourceneeds inadultmentalhealthservices. Australian and New Zealand Journal of Psychiatry,39,507–513.

Cleary,M.,Freeman,A.,Hunt,G.E.&Walter,G.(2006)Patientandcarerperceptionsofneedandassociationswithcaregivingburdeninanintegratedadultmentalhealthservice.Social Psychiatry and Psychiatric Epidemiology, 41,208–214.

ConsumerHealthSciences(2008)National Health and Wellness Survey 2008.Princeton:ConsumerHealthSciences.www.chsinternational.com

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 191

Gandon,P.,Jenaro,C.&Lemos,S.(2008)Primarycaregiversofschizophreniaoutpatients:Burdenandpredictorfactors.Psychiatry Research,158,335–343.

Goswami,M.(2006)Fromafamilycaregivertoacaregiveratthecommunitylevel–‘AshadeepModel’.InMental Health by the People(ed.R.S.Murthy).Bangalore:People’sActionforMentalHealth(PAMH).

Hiday,V.A.,Swartz,M.S.,Swanson,J.W.,Borum,R.,Wagner,H.R.&D’Cruz,P.(2002)Familiesinsociety.Journal of Contemporary Human Services,83,416–430.

Janardhan(2006)Communitymentalhealthanddevelopmentmodelevolvedthroughconsultingpeoplewithmentalillness. In Mental Health by the People (ed. R.S. Murthy). Bangalore: People’sAction for Mental Health(PAMH).

Johnson,D.L.(1994)Currentissuesinfamilyresearch:Cantheburdenofmentalillnessberelieved?InHelping Families Cope with the Mental Illness (eds.H.P.Lefley&M.Wasow),pp309–328.Newark,NJ:HarwoodAcademy.

Kare, M.,Thirthalli, J.,Varghese, R.S., Ross, D., Reddy, K.S., Jagannathan,A.,Venkatasubramanian, G. &Gangadhar,B.N.(2008)Reducingthedelayintreatmentofpsychosis.Wheredoweintervene?Astudyoffirst-contactpatientsinNIMHANS.BestPosterAwardattheRichmondFellowshipAsia-PacificConference2008onRehabilitationAcrossCultures. Bangalore:NIMHANS.

Leff, J. (1994)Working with families of schizophrenic patients. British Journal of Psychiatry, 164 (Supp 23),71–76.

Madan,G.R.(1987)Indian Sociology. Revised Fourth Edition.NewDelhi:AlliedPublishersPrivateLtd.Magliano,J.,Fadden,G.,Economou,M.,Held,T.&Xavier,M.(1998)Burdenonthefamiliesofpatientswith

schizophrenia: Results of the BIOMED 1 Study. Social Psychiatry and Psychiatric Epidemiology, 33(9),112–223.

Murthy,R.S.(2006)Mental Health by the People.Bangalore:People’sActionforMentalHealth(PAMH).Murthy, R.S. (2007) Family and Mental Healthcare in India. Bangalore: People’sAction for Mental Health

(PAMH).North,C.S.,Pollio,D.E.,Sachar,B.,Hong,B.&Isenberg,K.(1998)Thefamilyascaregiver:Agrouppsychoeducation

modelforschizophrenia.American Journal of Orthopsychiatry,68(1),39–46.OfficeoftheRegistrarGeneralandCensusCommissioner,India(2001)Census of India 2001.NewDelhi:Officeof

theRegistrarGeneralandCensusCommissioner,India.Padget,D.K. (1998)Qualitative Methods in Social Work Research: Challenges and Rewards.NewDelhi:Sage

Publications.Padmavathi,R.,Rajkumar,S.&Srinivasa,T.N.(1998)Schizophrenicpatientswhowerenevertreated–Astudyin

anIndianurbancommunity.Psychological Medicine,28,1113–1117.Phelan,M.,Slade,M.,Thornicroft,G.,Dunn,G.,Holloway,F.,Wykes,T.,Strathdee,G.,Loftus,L.,McCrone,P.&

Hayward,P.(1995)TheCamberwellAssessmentofNeed:Thevalidityandreliabilityofaninstrumenttoassesstheneedsofpeoplewithseverementalillness.British Journal of Psychiatry,167,589–595.

Solomon,P.&Draine,J.(1994)Examination of Adoptive Coping Among Individuals with a Seriously Mentally Ill Relative.Unpublishedpaper.Philadelphia:HanermanUniversity,DepartmentofPsychiatryandMentalHealthScience.

Srinivasan,N.(2006)Togetherwerise–KshemaFamilyPower.InMental Health by the People(ed.R.S.Murthy).Bangalore:People’sActionforMentalHealth(PAMH).

Stewart,D.W.,Shamdasani,P.N.&Rook,D.W.(2007)Focus Groups – Theory and Practice. Second Edition.Applied Social Research Methods Series, Vol 20.NewDelhi:SagePublications.

Thara,R.,Padmavathi,R.,Kumar,S.&Srinivasan,L.(1998)BurdenAssessmentSchedule:Instrumenttoassessburdenoncaregiversofchronicallymentallyill.Indian Journal of Psychiatry,40,21–29.

Wancata,J.,Krautgartner,M.,Berner,J.,Scumaci,S.,Freidl,M.,Alexandrowicz,R.&Rittamannsberger,H.(2006)The ‘Carers’ needsAssessment for Schizophrenia’. Social Psychiatry and Psychiatric Epidemiology, 41,221–229.

Winefield,H.R.&Harvey,E.J.(1994)Needsoffamilycaregiversinchronicschizophrenia.Schizophrenia Bulletin, 20(3),557–566.

WorldHealthOrganization(2001)Atlas: Country Profiles on Mental Health Resources 2001.Geneva:WorldHealthOrganization.

192 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

APPENDIX

Table 1 Needs expressed by caregivers in FGD-1

1. Informationonhowtobringthepatienttothedoctor 2. Skillstomotivatepatientwhoisnottakingmedication 3. Contactdetailsofdoctors 4. Skillstomakepatientcooperatewithparentsathome 5. Knowledgetohandlesexproblems/marriageissuesofpatients 6. Skillstocontroluncooperative/demandingpatient 7. Skillstohandleemergencysituations(medication,etc) 8. Referraltogroupsinlocalcentres/dayhomes 9. Skillstohandlesymptomsofpatient10. Skillstomanagepatientswhoarenotgoingoutside–e.g.nottalkingwithrelatives11. Skillstocontroltheangeroutburstsofthepatient12. Needforpsychotherapyforthepatient13. Skillstomotivatepatienttodailyactivities14. Concessionsforcaregivers15. Knowledgeonhowtoadmitviolentpatients16. Knowledgeonhowtobalanceworkandpatientcare17. Techniquestocontrolcaregivers’anger18. Techniquestomanagestressofcaregivers–negativefeelings19. Officialrulesrelaxingforcaregiversatwork20. Directives/pamphletsdealingwithvarioussituationsforothercaregivers21. Educatingsocietytominimizestigmainsociety

Table 2 Needs expressed by caregivers in FGD-2

1. Educationaboutillness/medicines(massmedia,schoolmentalhealthprogrammes,doctorsetc.) 2. Multidisciplinaryteamstodealwithpatient(s)/caregiver(s) 3. Toknowhowtomotivatepatientfortreatment 4. Privateservicestohelpcaregiver(s) 5. Skillstotacklepatientsiftheyrefusemedication 6. Skillstomotivatepatient(s)tofollowdailyschedule 7. Skillstomotivatepatient(s)tomaintainself-care(e.g.teachinggirlchildrentomanageself-careduring

menstruation) 8. Skillstotacklingpatient(s)insocialsituations 9. Skillstomanagedemandingpatients10. Skillstomotivatepatient(s)tocooperateinhouseholdactivities11. Governmentpolicies(economichelp)12. Rehabilitationcentreforpatient(s)13. Toknowhowtoimprovepatients’lackofconcentration14. Skillstomotivatepatientstosocialize15. Skillstotacklesymptomsofpatient(s)16. Skillstomakepatient(s)listentoparentsathome17. Skillstohandleunpredictablebehaviourofpatient(s)18. Facilitiestohelpworkingparentsiftheyneedtoleavefemalepatientsathomealone19. Skillstohelpparentsgainconfidence(thattheycanhandlethepatient)

JAGANNATHANET AL.:AQUALITATIVESTUDYONTHENEEDSOFCAREGIVERS 193

Table 3 Needs expressed by caregivers in FGD-3

1. Skillstomanageproblemsofsocialbehaviourinpatient 2. Techniquesonhowtofeedpatientiftheydonoteat 3. Techniquestohelppatientimprovepeerrelationshipissues(sister,brother,kidsetc.) 4. Skillstomotivatepersonalcareofthepatient 5. Skillstodealwithdifficultyintakingthepatienttothedoctor 6. Skillstodealwithdifficultyinadministeringmedicines 7. Skillstomotivatingpatientwhoisnotgoingout 8. Toknowhowtocommunicatewiththepatient 9. Toknowhowtohandleproblemsinmarriage10. Patientbeatingthekids/relatives–howtomanage11. Skillstomanage/balancework–personallife12. Skillstocontrolpatientfromquarrellingwithneighbours13. Financialconcessionsfromgovernment/NGO/others14. Skillstocontrolangrystateofthepatient15. Skillstomanageviolentpatient16. Skillstomanagecaregivers’depressivefeelingsleadingtosuicidalthoughts17. Skillstomanageunpredictablebehaviourofpatient18. Techniquestomotivatepatientswhodonotlikegoingoutsideandearning19. Skillstomanageincreasedsexualinterestsofpatient20. Knowledgeonhowtomanagesymptomsofpatient–e.g.self-talk/laughteretc.21. Skillstomanagecaregivers’emotions:(a)anger;(b)sadness;(c)fear

Table 4 Needs expressed by caregivers in FGD-4

1. Skillstoencouragepatientswhodonottakemedicines 2. Skillstomotivatepatientswhodonotcareforself 3. Skillstomanageaggressivepatients 4. Techniquestoencouragepatientswhodonottakefood 5. Techniquestoencouragepatientswhosesocialinteractionislow 6. Techniquestomotivatepatienttogoforjob 7. Skillstobringpatienttohospitalfortreatment 8. Techniquestoencouragepatientswhoarenotactive 9. Techniquestohelppatientscopewiththedemandsofthejobandmaintainit10. Techniquestocontrolpatient’sincreasedspending11. Techniquestocontrolpatient’sincreasedsmoking12. Skillstoregularizepatientswhoareirregular/havenodailyschedule13. Skillstoimmediatelycontrolpatientincrisissituations14. Educatethepatientabouttheillness,ifhehasnoinsight15. Knowledgeonhowtocontrolpatientsymptomsliketalkingtoself16. Knowledgeonhowtohandlepatient’ssleeplessness17. Knowledgeonhowtohandlepatient’swanderingbehaviour18. Techniquestocontroldepressivefeelingincaregivers19. Skillstomanagenon-cooperativepatient20. Financialhelp21. Skillstomanagedemandingbehaviourofpatient22. Socialsupport23. Knowledgeonhowcaregiverscantakeouttimefortheirpersonallife

194 INTERNATIONAL JOURNAL OF SOCIAL PSYCHIATRY 57(2)

Table 5 Needs expressed by caregivers in FGD-5

1. Skillstopushpatienttodoworkiflazy 2. Skillstomotivatepatienttodotheirself-care/activities 3. Techniquestomotivatepatientswhodonotindulgeinwriting/reading 4. Techniquestomotivatepatientswhodonotdoanywork 5. Skillstomotivatepatientswhodonottakemedicines 6. Techniquestoreducebidi(nicotine)intakeinpatients 7. Techniquestocontrolangeroutburstsinpatient 8. Techniquestomanagereducedsleepinpatient 9. Techniquestomanagesymptomslikeself-talkinginpatient10. Techniquestomanagepatientbehaviourlikepacing,restlessness11. Skillstomanageabnormalbehavioursinpatient12. Techniquestohelppatientswhoarenotabletosustainajob13. Skillstohelpimproveattention/concentrationinpatients14. Self-helpcentresinvillages15. Knowledgetodealwithincreasedsleepduetosideeffectsofmedicationinpatient16. Knowledgetodealwithweightgaininpatients(duetoillness/effectsofmedications)

A.Jagannathan,PhDScholarofDepartmentofPsychiatricSocialWork,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),Bangalore,India.

J.Thirthalli,AssociateProfessorofPsychiatry,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),HosurRoad,Bangalore–560029,India.

A.Hamza,AssistantProfessorofPsychiatricSocialWork,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),HosurRoad,Bangalore–560029,India.

V.R. Hariprasad, Senior Research Fellow in Department of Psychiatry, National Institute of Mental Health andNeurosciences(NIMHANS),Bangalore–560029,India.

H.R.Nagendra,Vice-ChancellorofSwamiVivekanandaYogaAnusandhanaSamsthana(SVYASA),Bangalore,India.

B.N.Gangadhar,ProfessorofPsychiatry,NationalInstituteofMentalHealthandNeurosciences(NIMHANS),HosurRoad,Bangalore–560029,India.

CorrespondencetoJagannathanAarti,196‘Srinidhi’,1stFloor,12thMAIN,4thBlock,Koramangala,Bangalore–560029,India.

Email:jaganaarti@gmail.com