(Problem Statement: A Study to



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1 |NAME OF THE CANDIDATE |Mr. PRUDHVI RAJ P |

| |ADDRESS |GOLDFINCH COLLEGE OF NURSING, |

| | |# 150/24, KODIGEHALLI MAIN ROAD, MARUTHI NAGAR, BANGALORE – 92. |

|2 |NAME OF THE INSTITUTION |GOLDFINCH COLLEGE OF NURSING |

| | |MARUTHI NAGAR |

| | |BANGALORE-560092 |

|3 |COURSE OF STUDY & |M.Sc. NURSING |

| |SUBJECT |PSYCHIATRIC NURSING |

|4 |DATE OF ADMISSION TO COURSE | 30-06-2011 |

5. TITLE OF THE TOPIC

“A STUDY TO ASSESS THE PSYCHOLOGICAL AND SOCIAL PROBLEMS OF SIGNIFICANT FAMILY MEMBERS OF MENTALLY ILL PERSON IN A SELECTED SETTING AT BANAGLORE”

6.0 BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Smile at each other; make time for each other in your family”

-Mother Theresa

A great saying is there “If you lose everything in your life it’s not at all a problem, if you have a good family”. A Family unit is a unit which builds up a person’s personality. How you behave and what you become in life is very much dependent on your family life. Psychologists believe that a child learns the most from his/ her family life. The way your family members deal with you has a life long effect on your personality.

The life with your family is very important it plays a major role in your development into the person you become. Those children who belong to the families which have a rich education background tend to learn more. Similarly, for example, children who belong to a family from which a few of the people are in the field of professional sports, the kinds tend to have interest in sports and they also plan to go into the same field. Thus it is the effect of your family life which guides you to decide what profession you want to do as an adult.

Family life is also important in the sense that it gives you your basic strength as a person. The people who have a smooth and well settled family life are generally less scare of life. Those who are a part of a broken family are generally less confident. These people always expect the worst in life. This is a general state of mind resulting in building up of a negative personality.1

In the same way having a family member with a mental illness can be very stressful. Whether the ill person is a son, daughter, husband, wife, brother or sister. You will be affected by their illness too. A person with a psychiatric disorder often needs much love, help and support. At the same time, the problems, fears and behaviour of your ill relative may strain your patience and your ability to cope.

There are many different kinds of mental illness and each has its own symptoms during period when your relative is ill, he/ she may be demanding and disruptive, or extremely withdrawn and inactive. In fact, ill person’s behaviour may keep on changing because the symptoms may fluctuate.

Much of the unusual behaviour associated with some mental illness is beyond the control of the person with the illness. At times, your ill relative may embarrass you in front of friends and neighbours. Because it is difficult to talk about your relatives problems with people outside your immediate family, you may not offer an explanation. Many families, unfortunately, give up their own social lives when a relative becomes mentally ill because they are nervous about inviting people into their home.

While it takes courage to tell your friends and family about your relative’s illness, it is not good to isolate yourself. Try to find ways to explain the illness and treatment to others, and to talk about the discomfort you and other people feel as a result of your relatives’ behaviour.2

To be suffering from a psychiatric condition is by many described as a painful and sometimes traumatic experience. When someone close to you goes through this you not only be affected because she / he is in pain, your life will be affected in a number of other ways. IT can affect your financial situation, how and where you live and work. The emotional effects can be a constant worry which in turn can cause physiological problems for family members as well. Some of the family members have had to give up their own recreational pursuits. Some at one or more occasions, leave their job. An even larger number felt isolated and restrained from seeing other people. Half of the family members may develop psychological or social problems of their own to the extent that they need help and support. Symptoms described by family members were sleeping problems, stomach pain or depression. It is not unusual that family members are carrying around feeling of guilt and shame because they think they are to blame for the development of the psychiatric illness or for not knowing how to handle this kind of family crisis. A consequence of feeling guilty and ashamed is that it might feel difficult talking to others about what you are going through. A lot of the times it helps to talk to other people who have similar experiences as you have.

When it comes to children they are often the invisible victims. Having a parent with al psychiatric illness brings about a lot of difficulties. As a child it is hard to understand a parent is not feeling well and many blame themselves. This can result in a low self esteem and a poor self image. The children might also be embarrassed to bring friend home or might not be allowed to . Many children therefore grow up to feel different that everybody else around them and end up lonely and isolated from peers of their own age. Therefore it is very important to look for signs that a child is not feeling well. The more a child gets the appropriate support the less likely it is that she/ he develops psychological problems of his / her own.3

Hence, by doing proper assessment of problems faced by family members of mentally ill in the beginning stage itself we can prevent the further deterioration of the family.

6.1 NEED FOR THE STUDY

A family is the same as it is for you with your own body. You want all the parts of it to be well. For example, your finger it is not different from you, when it hurts, you take care of it. Like this, our family takes care of us all. If any one member of the family is facing a problem, it will affect the whole family. So if a family member is facing a psychiatric problem, it will have an impact on others.

According to a Swedish study, half of the family members have had to given up their own recreational pursuits. A fifth had to, at one or more occasions leave their job. An even larger number stated they have felt isolated and restrained from seeing other people. Half of the people in this study claimed they develop psychological or social problems of their own to the extent that they need help and support. Symptoms described by family members were Sleeping problem, stomach pain or depression.3

A study stated that as much as 50 percent of the mentally ill population also has a substance abuse problem. The drug most commonly used is alcohol, followed by marijuana and cocaine. The incidence of abuse is greater among males and those in the age bracket of 18 to 44.4

It is estimated that approximately 450 million people worldwide have a mental health problem. W.H.O stated that family members are often the primary caregivers of people with mental disorders. They provide emotional and physical support, and often have to bear the financial expenses associated with mental health treatment and care. It is estimated that one in four families has at least one member currently suffering from a mental or behavioral disorder.5

A study was aimed at evaluating a caregiver burden questionnaire generated in collaboration with Israeli family members of mentally ill individuals, and assessed the burden of Israeli caregivers as well as its relation to their age, gender and kinship relationship to the mentally ill individual. 53 family members answered the questionnaire. Factor analysis was performed, as well as calculation of internal consistency and validity. Hypothesis testing included the Pearson correlation for association of caregiver age with burden, and the Mann-Whitney test for gender difference in burden. Association of caregiver burden with Kinship relationship could not be assessed as nearly all participants (94%) were parents of a mentally ill individual. The basic psychometric properties of the questionnaire were sound. Mean burden was moderate. Caregiver age was not associated with burden. Females were significantly more burdened than males. Further participatory study of caregiver burden is recommended. Mothers of mentally ill individuals may require particular assistance.6

In the past 50 years, a shift toward community care and the deinstitutionalization of psychiatric patients has resulted in transferring of responsibility and day-to-day care to family members.7 In part, this shifting of responsibility has been caused by a deficit in community support services. The profound psychosocial, physical, and financial impact on the family of individuals with severe mental illness is comparable to that of persons with other illnesses such as Alzheimer’s disease or cancer. Worried, Tired and Alone, a 2003 report analyzing the issues affecting caregivers of people with mental illness in Western Australia, found that as a result of long-term care giving, the majority of caregivers surveyed experienced personal, emotional and physical strain on their lives and the loss of their personal freedom. Emotional impact such as Guilt, loss, helplessness, fear, vulnerability, and cumulative feelings of defeat, anxiety, resentment, and anger are commonly reported by caregivers. Caregivers may feel isolated, restricted from pursuing their own activities, and may be overwhelmed by a lack of support from friends, family and treatment providers. · Frustration in ensuring medication adherence; coping with disturbed or awkward interpersonal behavior and fatigue from continuous supervision of a family member have also been reported to add to caregiver burden. In addition, caregivers have reported great anxiety due to fear that their relative may attempt suicide. Worried, Tired and Alone found that many caregivers feel a deep and pervasive sense of fear and uncertainty as well as powerlessness and helplessness, often exacerbated by the unpredictable behaviors of the individual with mental illness experiencing a relapse.8

|22 |Bangalore |

|Diagnosis | |

| |No. of cases |Rate/ 1000 |

| | | |

|Epilepsy | | |

| |278 |7.82 |

|Organic brain syndrome | | |

| |4 |0.11 |

|Schizophrenia | |1.83 |

| |65 | |

|Mania |20 |0.56 |

| |28 |0.79 |

|Depressive Psychosis | | |

|Total no. of cases & |395 |11.1 |

|Prevalence rate/1000 | | |

|Population studied |35,548 | |

Most commonly reported behaviors were the reactions of violence, volatile mood swings, alienation, abusive language and the capacity of the individual to appear normal one minute and on the edge the next. Financial impact A loved one's mental illness may lead to a disruption of household and work routines and a loss of productivity for the family unit. Family members are often put in a position where they are required to pay for medical treatment for their loved one with a mental illness, as well as bear the brunt of a potential increase in medical costs for other family members. Physical impact ;Physical and mental health problems of caregivers increase for those providing the highest levels of care. Rates of caregiver depression have been estimated to range from 38% to 60%. Caregivers of family members with a higher number of symptoms and level

of cognitive impairment experience more depression. Similarly, there is a link between caregiver burden and symptoms of infectious illnesses (primarily upper respiratory illness) experienced by caregivers. The more severe the loved one's symptoms, the greater the number of infectious illnesses contracted by the

caregiver.9

Hence in this study the Investigator interested to assess the psychological and social problems of family members of mentally ill.

6.2 REVIEW OF LITERATURE

A review of the literature refers to an extensive, exhaustive and systematic examination of publication relevant to the research project. Most often associated with academic-oriented literature, such as thesis, a literature review usually precedes a research proposal and result section. The result of a literature review and analysis according to the style requirements for courses, journals, thesis, dissertation and grant proposal makes the presentation. A well structured literature review is characterized by a logical flow of ideas; current and relevant references with consistent appropriate.10

The review of literature is presented under the following aspects.

Section-A: LITERATURE RELATED TO PSYCHOLOGICAL PROBLEMS OF FAMILY MEMBERS OF MENTALLY ILL

A careful family history may provide not only help in the management of a patient's disorder but also the clues for screening and identifying other at-risk patients for whom either prevention or early intervention is appropriate. Obtaining a family psychiatric history has definite clinical benefit. A child of a schizophrenic mother has an eightfold increase in the risk for that disorder, as well as an increased risk for suicide. In the general population, anxiety neurosis has a prevalence of about 5%, which increases to about 50% in the offspring of persons with the disorder. Of persons with mania or depression, roughly two-thirds of the offspring between 5 and 15 years will be clinically depressed.

In these cases, a family history succeeds in identifying unsuspected cases of illness that need treatment and may suggest to the physician that a shattered family system exists. Finally, the detection of family roles and functioning will give assistance in achieving therapeutic goals and compliance. Not only may an individual's health or illness be a result of what happens in a family, but the family may be predictably altered by the illness of one of its members. Using family systems theory, some effective interventions may now be directed at altering the family's impact on illness. The family strengths and weaknesses, and its ability to withstand major stresses in the future, can be assessed. A good family history may reveal unexplained symptoms to be the manifestations of a stress-related or psychosomatic illness.11

A study mentioned that Schizophrenia is a severe mental illness, which is stressful not only for patients, but also for family members. Numerous studies have demonstrated that family caregivers of persons with a severe mental illness suffer from significant stresses, experience moderately high levels of burden, and often receive inadequate assistance from mental health professionals. Effective family functioning in families with schizophrenia may be influenced by a variety of psychosocial factors. The purpose of this article was to present a review of the social science literature related to families living with schizophrenia that has been published during the last three decades. There is general agreement in the literature that a multitude of variables affect families with a severe mental illness, such as schizophrenia. Therefore, this literature review examined the most frequently investigated variables (coping, psychological distress and caregiver burden, social support caregiver resiliency and depression, and client behavioral problems) as they are related to families and schizophrenia.14

A cross sectional study was conducted on care of the mentally ill has moved from institutions to the community. Care of mentally ill has moved from institutions to the community. Consequently, the burden of caring for these patients has transferred from institutional caregivers to families. The level of burden experienced by the family, as well as the acceptance by the patient of the care that he or she received, have a significant impact on the patient’s care. The purpose of this study was to identify factors that affect the sense of burden felt by family members caring for patients with mental illness at home in Japan.

A research was conducted on abuse of carers by relatives with severe mental illness. Background relatives often experience considerable problems looking after a family member with severe mental illness. The problems arising from verbal and physical abuse are not well researched or acknowledged. The aim is to examine the frequency with which family carers experienced verbal and physical abuse from relatives who were being looked after by a community mental health service and to identify the correlates and consequences of that abuse. One hundred and one clients and their family carers were interviewed. Supporting a previous study of patients on an acute admission ward, the experiences of verbal and physical abuse were positively correlated. Higher rates of abuse were associated with poor relationship between patients and their families and a history of poly-drug misuse and previous criminal offences on the part of the patient. Relatives experiencing higher levels of abuse were more likely to have symptoms of emotional distress and were related as experiencing more burdens.

Verbal and physical abuses are not infrequent problems facing family members caring for a relative with severe mental illness. Some of the risk factors for such abuse can be identified. Care plans for family carers could usefully target risk reduction strategies to minimize the occurrence of abuse.16

A study was conducted on ‘ The needs of mentally ill parents’ stated that approximately 10% of women and 6% of men who become parents will experience mental health problems and a significant proportion of these have a severe psychiatric illness. Method of this study is a literature review. The results of this study shows that

Mothers with severe mental illness have a wide range of complex health and social care needs in addition to their parenting needs, which must be addressed by services in pregnancy and postpartum to optimize outcomes. There is limited evidence on the needs of fathers with severe mental illness but they may have a greater number of needs than women, and a greater need for training in parenting skills than women’s suffering from severe mental illness. Parents with mental illness may experience stigma and discrimination, and fear accessing services due to fears of losing custody of their child. Lastly author concluded that although a significant proportion of parents with severe mental illness do lose custody, many can successfully parent if adequate support is available and needs are assessed and managed by a multidisciplinary team.17

A study enrolled mentally ill mothers from Mecklenburg-Vorpommern, Germany, with children between the ages of 0-3 years . Using different self and expert ratings, psychological symptoms, social support , parental stress, and behavior of the children were assessed. Teenage mothers and adult mothers were compared using the mean values of the data. The data of 104 mothers were included, 46.1% of mothers were younger than 20 years of age when they gave birth. All mothers show a variety of psychological problems. While adult mothers had significantly more affective and anxiety disorders, teenage mothers had significantly more eating disorders, and sexual abuse in their histories. Young mothers reported subjectively significantly less social support and more parenting stress than older mothers.18

A study was conducted on the experience of mothers getting assistance for their adult children who are violent and mentally ill. If individuals with mental illness become violent, mothers are most often victims, yet there is little available research addressing how, when, and from who mothers seek help for themselves or their children when they become victims of this form of familial violence. The objectives of this study were to describe how mothers understood violence their adult children with mental illness exhibited toward them and to articulate the process mothers used to get assistance and access mental health treatment when this violence occurred. Method adopted for this was: “Grounded theory” methods were used to explore and analyze mothers' experiences of violence perpetrated by their adult children with mental illness. Eight mothers of adult children who are violent with a diagnosed Diagnostic and Statistical Manual of Mental Disorders Axis I disorder participated in one to two open-ended interviews. Mothers were of diverse ethnic backgrounds.

The results obtained for this study were Getting immediate assistance involved a period of living on high alert, during which mothers waited in frustration for their children to meet criteria for involuntary hospitalization. This was a chaotic and fearful period. Fear and uncertainty eventually outweighed mothers' abilities to manage their children's behavior, at which time they called the police or psychiatric evaluation teams who served as gatekeepers to mental health treatment. Mothers accepted the consequences of being responsible for their children's involuntary hospitalization or of being left home with their children if the gatekeepers did not initiate involuntary hospitalization. Mothers can identify signs of decomposition in their children who are ill and recognize their need for hospitalization. They cannot, however, always access mental health treatment due to their children's refusal or failure to meet legal criteria for involuntary hospitalization. Mothers' inability to intervene early sometimes results in their own violent victimization.19

About a third of all inpatients in psychiatric hospitals are parents of children aged below 18 years. The mental illness of a parent and especially the need of inpatient treatment burdens families. This study was contributed to assess parental stress, behavioral and emotional problems of the children and the needs of psychiatric inpatients for support. Barriers and hindrances as well as positive experience with support for their children were assessed. All psychiatric hospitals in a county with about 1.5 million inhabitants in South-West Germany participated in this study. From 643 inpatients after drop-out 83 (54 female, 29 male) patients with non full aged children were questioned with inventories as the SDQ, the PSS and further assessments. Diagnoses and biographic data were assessed by the documentation of the German Association of psychiatry and psychotherapy. Parents reported about an increased level of stress by parenthood (PSS mean 41.9, SD 9.4). Psychopathology of the children influenced the stress of the mentally ill parents. 40% of the patients are dissatisfied with the care of their children during their inpatient treatment, but 51% have strong resentments against the youth welfare custodies and do not ask for support. Our results prove the high negative attitude of mentally ill parents against youth welfare service which must be reduced by active information policy and offers in collaboration with the treating psychiatrist of the parents.20

Section-B: LITERATURE RELATED TO SOCIAL PROBLEMS OF FAMILY MEMBERS OF MENTALLY ILL

A descriptive study was conducted on chronic mentally ill population is a diverse group comprising of the patients with different problems of varying degree of disability and different levels and types of needs. The present study aims at assessing the burden faced by the families and the needs for rehabilitation among beneficiaries of a rural mental health camp in South India. Using the interview schedule for the assessment of family burden and rehabilitation needs. 50 Caregivers were interviewed. The results indicated mild to moderate objective burden experienced by the families. Highest burden was perceived in the domain “disruption of family activities” followed by “Financial burden”.12

A study was conducted using a cross-sectional method. A Questionnaire was delivered to 30 patients and 30 family caregivers of patients who left a rural psychiatric hospital and returned home for care. During follow-up home visits, a nurse enrolled the patients in the study and delivered the Questionnaire, which was filled out by the patients and family members. Demographic data on the patients were collected during a 30-40 minute interview with each family.

The results of the study revealed that patients’ satisfaction with daily life and their ability to perform tasks had a strong impact on the sense of burden felt by the caregivers. This is important because patients could often be taught how to perform a task, but their willingness to perform these tasks was often the problem within the home. This finding makes sense and is consistent with findings of other studies. These results suggest that providing support that enhances the quality of life of patients with mental illness may indirectly help to reduce the sense of burden felt by family members caring for them.15

A study was conducted on family stigma, which is defined as the prejudice and discrimination experienced by individuals through associations with their relatives, methods; The author describe the family stigma and present research related to mental illness stigma experienced by family members. Research indicates this type of stigma negatively impacts family members and relative with mental illness. Results: The author also present strategies to eliminate stigma and discuss implications for the training goals of psychiatrists throughout the text. Conclusion: The author end this article with recommendations for psychiatry training goals.13

This study was conducted on Socio-economic conditions of relapsed patients admitted in a Nigerian Mental Health Institution. Relapse in psychiatric disorders is highly distressing, costly and engenders burn-out syndrome among mental-health workers. Aim is to study the socio-economic factors associated with relapse in individual admitted with psychiatric disorders and the pattern of socio-economic impact of relapse in those groups.. A cross-sectional survey of all relapsed patients without cognitive deficit admitted into the federal Neuro-Psychiatric Hospital, Lagos, Nigeria between June and October 2007 was conducted using a self-validated Structured Interview Schedule (Relapse Socio-economic Impact Interview Schedule) and Key Informant Interview Guide. Secondary data were elicited from the patient folders, case notes, ward admission registers and nominal rolls. Data were summarised using mean, standard deviation, frequency and percentiles. Pearson's moment correlation coefficient was used to test the association among variables. The Mann-Whitney U-test was used to compare the pre-morbid and the post-morbid states. This study involved 102 respondents. Their mean age was 36.5± 9.8 years, mainly of male gender (72.5%) suffering from schizophrenic disorder (37.8%). Relapse and re-admission ranged between 2 and 12. Unemployment rate, marital separation and divorce increased more than 5-fold from pre-morbid to morbid states. Few (4.9%) could still settle their hospital/drug bills on their own, while most (95.1%) depended on family, philanthropist and government/waivers to pay for their bills. Their social relationships were negatively influenced with most of them expressing social isolation and low quality of life. There were significant relationships (P ................
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