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There is a dearth of specialized mental health services for Indian paramilitary service personnel. Those requiring psychiatric evaluation are referred to government psychiatric services often with minimal information. Hence, major diagnostic and decision making relies on the psychiatrist's clinical evaluation and judgment. The aim of the present study was to quantitatively evaluate the paramilitary referrals to psychiatric services at a tertiary care referral center.
A retrospective chart analysis of all consecutive referrals by various Indian paramilitary services to a tertiary care hospital (2008-2010) was carried out.
Among the sample of 18 referrals, all were males (mean age: 37 years ± standard deviation (SD) =7.79). Various reasons for referral included: Evaluation of fitness for duty (83.3%), fitness to handle firearms (16.7%), and for disability certification (5.6%). There were no informants at all in 22.2%, and family members were available in only 11.1%. Hence, most referrals were admitted to the psychiatry ward for observation for various lengths of time. The mean duration of assessment (outpatient and inpatient) was 17.89 days (SD = 20.74) and final reported diagnoses were schizophrenia, depression, and bipolar disorder in 16.7, 11.1, and 11.1%, respectively. There was concurrent history of alcohol and nicotine dependence (40%). A large group (40%) was diagnosed not to suffer from a major mental illness, while a firm and final diagnosis could not be arrived at in 16.7% subjects. Only one subject was given the fitness to handle firearms, fitness for duty was refused in three (16.7%) subjects, and one subject was referred to neurology after being diagnosed as a case of seizure disorder.
There is an urgent need for intensive training both to paramilitary physicians as well as to general hospital psychiatrists regarding proper assessment of paramilitary personnel, as there are frequent chances of the cases being undiagnosed or improperly diagnosed.
Apart from securing the nation, the paramilitary forces (PMF) performs other important duties such as internal security, election duties, and disaster management. PMF personnel run a high risk of being exposed to acute stress since violent and threatening encounters are part of their work situation. Moreover, since they do not have a fixed work pattern and are required to meet expected and unexpected emergencies for unspecified periods of time, the culminative pressure chronically increases stress on a day-to-day basis. They are posted in non-family sites where supporting influence of the family is absent. On the other hand, since the wife has to take care of the entire family burden, pressure from the family builds up as well. With improved communication, the individual is exposed to these family pressures over the phone.
In these stressful living or working situations, the PMF personnel are likely to experience multitude of mental health problems, such as negative emotions (e.g., fear and anger), physiological overreactivity (e.g., palpitations and increased blood pressure), and dysfunctional cognitions (e.g., pessimistic thoughts about oneself). These stress reactions can degrade concentration and task performance further leading to changes in job performance and quality of life.[1,2] Psychiatric symptoms after combat have been a feature of many wars with majority reporting of posttraumatic stress disorder.[3,4]
In the Indian subcontinent, studies on paramilitary and police forces have mainly focused on mental health problems amongst police and defense personnel self-reporting mental health issues (28.6-48%). Studies have identified factors intrinsic to the job as major contributors to stress related problems among these personnel. As many as 85% officers may be suffering from stress due to their occupation.[6,7] One study reported domestic stresses (45%) playing more role than occupational (26.5%) and physical factors as drug intake or infection (13.5%).
Along with high incidence of ischemic heart diseases and acute myocardial infarction, studies in these personnel report of psychiatric disorders; commonly adjustment disorders, posttraumatic stress disorder, depressive disorders, anxiety disorders, substance abuse, and personality disorders.[10,11] In a study of Central Industrial Security Force (CISF) personnel at National Industrial Security Academy, Hyderabad, prevalence of psychiatric morbidity was reported to be 28.8% with the majority suffering from generalized anxiety disorder and major depressive disorders.
In spite of high prevalence of mental morbidity, these forces suffer from a shortage of mental health personnel. Hence, those suffering or suspected of a mental disorder are referred for evaluation to civilian facilities in the neighborhood. Dr. RML Hospital, New Delhi (RMLH) has long been one such referral center. Psychiatric assessment of paramilitary referrals is difficult and complicated. For one, such personnel are transferred from their place of posting to the evaluation center, so reliable and adequate information about what happened, is usually unavailable. Psychiatric services in general hospital thus usually obtain detailed information from family members accompanying the patient. In their absence, paramilitary personnel have often to be hospitalized for observation and review of their psychiatric status. Hence, the major diagnostic and decision making heavily rely on the psychiatrist's detailed clinical assessment and judgment.
The present study was undertaken to describe paramilitary referrals to this tertiary care psychiatric center for diagnosis and evaluation over a 3 year period.
This retrospective chart analysis of medical examination (“MIT”) files was conducted at the Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India. The study sample included all consecutive patients referred by Indian paramilitary services for assessment by Psychiatric Medical Board from 1st January 2008-31st December 2010.
Patients are referred to Psychiatric Medical Board for opinion from doctors of their respective PMFs. The Psychiatric Medical Board constitutes two or more psychiatrists, assisted by other mental health personnel, who evaluate the patient independently. The patient is thoroughly assessed, as an inpatient if necessary. The clinical information is collected from the patient himself, his attending coworkers or family members as and when available using a semistructured format for sociodemographic profile, clinical history, and physical and mental state examination. Assessments also include a Drug Abuse Monitoring System Performa, Fagerstorm Test for Nicotine Dependence, and Alcohol Use Disorder Identification Test in all cases. Appropriate referrals from other medical disciplines are sought as needed and formal psychological testing is carried out where necessary. Observations by junior and senior residents, nurses, psychiatric social workers, and occupational therapists are collated. The diagnosis is based on International Classification of Diseases-10 and the final opinion of the Board is decided after a consensus is reached.
The total sample consisted of 18 subjects during the 3 year period of study. The sociodemographic characteristics of the sample are presented in Table 1.
All the subjects were males and majority of them belonged to the age group of 30-39 years with a mean age of 37 years (standard deviation (SD) =7.79, range 27-53). As shown in Table 1, majority of the subjects were married, belonging to an urban background, Hindu by religion, and the primary earning member of their families. Majority (72.2%) had service duration of less than 10 years with no legal cases pending against any of them.
Reason for referral was fitness for duty in more than three-fourth of the subjects, while others were referred for assessing fitness to handle firearms or for disability certification [Figure 1]. Only 5.6% subjects were referred for assessment of fitness for duty as well as fitness to handle firearm. Family members were available as informants in only 11.1% subjects.
There was a history of previous psychiatric opinion in only 16.7% cases. There was a need for admission in 16.7% cases for detailed evaluation and observation, where the lack of a family member was a major constraint. The mean duration of assessment at RMLH was 17.89 days (SD = 20.27; standard error (SE) = 0.54).
About 40% patients had a history of alcohol and tobacco dependence with mean duration of use of 13.4 years (SD = 7.79). A family history of alcohol abuse, psychosis, or suicide was noted in 5.6% subjects each. Assessment revealed anxious personality traits in 5.6% of subjects and history of self-harm in 5.6%. About 28% reported history of a significant stressor prior to symptom onset.
No major psychiatric disorder was diagnosed in 33.3% [Table 2 and Figure 2]. These subjects had no history of psychiatric disorder or psychiatric referrals in the past and had been referred for ‘fitness for duty’. A final confirmed diagnosis could not be reached in 11.1% subjects. In final opinion, 16.7% subjects were declined fitness for duty, one was declined fitness to handle firearms, and another was referred to neurology for treatment of epilepsy. About 50% of subjects were assessed to be in need for further psychiatric treatment.
The current study is a retrospective chart analysis of psychiatric medical board files during a 3 year period. It was observed that there were only 18 referrals for psychiatric assessment in a 3 year period with only 5.6% (one subject) being referred for disability certification. With the general population prevalence rate of mental and behavioral disorders in India ranging from 9.54 to 370 per 1,000 population, the referrals in current study were low. This was not unexpected because PMFs may be expected to be at the healthier end of the population, or because ill members may have been sent out of service early on. It could also be due to low awareness for mental health disorders and associated disability benefits in this subpopulation.
The majority of subjects referred for evaluation had been in service for less than 10 years as has been observed in previous studies.[8,14] Thus, younger individuals with less exposure and experience appeared to be more at risk for stress and subsequent psychiatric referrals. It may also reflect the usual age of onset of psychiatric disorders (i.e., young adulthood). Screening for psychiatric disorders in early tenure of service may need to be better organized. Possibly work related stress may be higher in the less experienced younger personnel. Studies in military forces have reported that service personnel are at risk of psychological distress following deployment.[16,17] More intensive training for handling stress of service may address this problem.
More than one-third of subjects reported substance dependence which corroborates with the Indian data on drug abuse in general population.[18,19] Saldanha and Goel (1992) studied subjects admitted into a zonal referral hospital of the armed forces over a period of 2 years and reported that alcohol dependence syndrome constituted the third largest group among the psychiatric population. Other Indian studies have also reported alcohol use to be higher in personnel deployed to areas of low intensity conflict.[21,22,23] Studies in military forces report of army personnel having more alcohol dependence as compared to their navy or air force colleagues.[20,24] The prevalence is reported to be decreased after Army Order 3 and 11/2001 was introduced.
About 33% subjects were found to have no psychiatric disorder on assessment. This raises the concerns that whether these were unnecessary referrals raising possibility of either doubts or a genuine unawareness of mental health symptoms. It could also be possible that these personnel were referred as a sort of warning. There is therefore need for incorporating psychiatric services as essential medical facility in these forces including psychiatrists, psychologists, and psychiatric social workers.
Majority of the subjects had a diagnosis of schizophrenia or bipolar disorder (22.2 and 16.6%, respectively) among the study sample. Other studies in military personnel have differing findings with some reporting neurosis and others psychosis to be more common,[14,25] although the methodological measures varied.
All the subjects were male in our study possibly due to negligible female representation in PMF reportedly about 4.7% in CISF and less than 1% in others. But as female participation in armed forces grows, women's mental health issues will need to be addressed.
There were no informants available in 22.2% cases and no confirmed final diagnosis could be reached in 11.1% cases. While this reflects the general difficulties in psychiatric assessment, it also increases the possibility of misdiagnosis and inability to reach a conclusive diagnosis. The need for better assessment tools, refined history taking, and rigorous detailed serial mental state examinations become all the more essential.
There was history of a previous psychiatric opinion in 16.7% subjects and 16.7% subjects needed admission with the mean duration of assessment being 17.89 days. Possibly, only the more difficult cases with diagnostic or management problems were only referred. Less problematic cases may have been handled at the forces medical level. This also raises the need for extending Mental Health Act (MHA) admission criteria which currently is of 10 days, although it has a provision of extending to 30 days on court order.
We recommend high alert for high risk individuals and need for coping and ability enhancement programs as there was a history of significant stress prior to symptom onset in 28% subjects and acts of self-harm in 5.6% subjects. A survey of stress problems in Indian police personnel by Mathur (1993) reported that certain job related factors acted as specific stressors for the police such as their (1) work conditions, (2) work overload, (3) lack of recognition, (4) fear of severe injury or being killed on duty, (5) inadequate equipment, (6) shooting someone in line of duty, (7) antiterrorist operations, (8) confrontation with public, (9) lack of job satisfaction, and (10) police hierarchy.
We also recommend use of a structured Performa for referring force personnel to psychiatrist for evaluation, so that a minimum amount of information would be available for reaching a conclusive opinion [Figure 3].
The current study is limited in generalization due to its small sample size and hospital based data from one center only. There is an urgent need for an epidemiological study overseeing the nature and extent of mental health disorders in these highly stressful work situations.
Apart from the physical wear and tear, mental health problems generate significant dysfunction among paramilitary personnel. There is an urgent need for intensive training to psychiatrists regarding proper assessment of paramilitary personnel as there are frequent chances of the cases being undiagnosed or improperly diagnosed. The issue of providing fitness to handle firearms is of particular importance as these individuals are at high risk of stressful situations and prone to stress. As there is a high risk of stressful situations, these personnel need to be regularly assessed for mental health besides physical health.
Source of Support: Nil.
Conflict of Interest: None declared.