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Onset of acute and transient psychotic disorder in India: a study of socio-demographics and factors affecting its outcomes.

Introduction

Before the advent of the ICD-10, (1) acute psychosis as a group did not exist separately and was classified under the broad category of schizophrenia. In India, Wig and Singh (2) made the first observation regarding the existence of acute psychosis as a separate nosological entity. Their work pointed towards an acute-onset psychosis having florid symptomatology and good prognosis and also highlighted that the equivalent nosological entities in ICD were acute psychosis of uncertain origin and hysterical psychosis. Another study from India (3) considered the existence of 2 types of acute psychosis, namely, acute psychosis with and without stress. Singh and Sachdeva (4) suggested that "acute schizophrenia episode" was different from schizophrenia and manic depressive psychosis (MDP) and stressed that it should not be included under schizophrenia. One study (5) described reactive psychosis which had manifested psychopathology, personality traits, life events, and family history. The landmark Indian Council of Medical Research (ICMR) acute psychosis study (6) found that 35% of cases were categorised as schizophrenia, 25% as MDP, and 40% as non-organic psychosis as per ICD-9. Moreover, 52% of the cases of acute psychosis could not be classified into any of the diagnostic categories. (6)

Acute and transient psychotic disorder (ATPD) as a descriptive entity was recognised for the first time in 1992 when ICD-10 included it under psychotic disorder (F23) as a three-digit code. (1) Acute and transient psychotic disorder has certain key features, such as acute onset (within 2 weeks) and rapidly changing, variable polymorphic picture, which are accepted as defining criteria; stress may or may not be present with the condition. Recovery is complete within 2 to 3 months in most cases. (1)

Epidemiological data on the incidence of acute psychosis suggest that acute and transient psychosis is 10 times more common in developing countries than in developed countries. (7) Despite the long period since ATPD received a distinct nosological status, its status as a separate diagnostic entity has been questioned time and time again because of its diagnostic instability due to overlap of symptoms with schizophrenia and affective psychosis in many cases. Relatively few studies from India have examined the diagnostic validators of ATPD and conclusive data are lacking. In view of the need to define this category more precisely, the current study aimed to delineate socio-demographics (an antecedent diagnostic validator as per schema of Robin and Guze (8)) and clinical variables associated with the onset of ATPD, and how these affect the outcome (a predictive diagnostic validator) of the same.

Methods

A retrospective study was conducted in the Department of Psychiatry, SMS Medical College and Hospital, Jaipur, India. Case notes of all inpatients diagnosed with ATPD (according to the ICD-10 diagnostic criteria) from 1 January 2012 to 31 December 2012 were analysed. A total of 191 such subjects were identified. Of these, patients who were discharged against medical advice (n = 2) or absconded (n = 4) were excluded as clinical improvement could not be established in these patients. The socio-demographic data of the patients were collected on a self-designed performa. Information regarding presence of a stressor prior to the onset of illness, family history of any psychiatric illness, history of substance abuse, duration of untreated illness (DUI), month of onset of psychosis, and duration of hospital stay was recorded. Stressors were categorised into biological (i.e. causing hormonal and biochemical changes) and psychosocial (i.e. changes in social environment).

For the purpose of analysis, duration of hospital stay was used as a proxy for clinical outcome and treatment response. The response was arbitrarily divided into 2 groups: early response (duration of stay < 7 days) and late response (duration of stay [greater than or equal to] 7 days). The 2 groups, thus formed, were compared with respect to all variables.

Descriptive statistics were used to express data with frequencies and percentages. The Chi-square test and Fisher's exact test were used, where appropriate, to examine the association between variables. All analyses were performed with the help of SPSS Windows version 17.0.

Results

A total of 185 subjects were diagnosed with ATPD during the study period. Table 1 shows the socio-demographic features of the study subjects. Overall, 91 (49%) patients were males and 94 (51%) were females. Most of the patients (60%) were aged between 20 and 39 years, and 68% were married. The majority (74%) was unemployed; 24% of the patients were illiterate and most patients were educated up to middle school. The bulk of our study population came from rural areas (88%). Almost half of the patients (52%) were living in a nuclear family, 43% lived in a joint family and only 4% lived in a nuclear extended family. Among the socio-demographic variables, only age (p = 0.05) and marital status (p = 0.02) significantly affected our study outcome (Table 2).

As shown in Table 3, 46% of the patients had a precipitating factor for their illness. Types of stressors could be grouped into biological (including fever and child birth) and psychosocial (including quarrel within family or friends, financial loss, loss of loved ones, job loss, and marriage). Fever was found to be a major individual precipitating factor in most of the cases reporting the presence of a stressor (33%). Only 27% of the patients were using any sort of substance prior to illness, and 23% had a family history of psychiatric illness. Overall, 38% of the patients had DUI ranging from 7 to 15 days, and this was the only factor with significant influence on our study outcome (Table 4). The month of onset of ATPD in the study sample is shown in the Figure. In most cases (54%), the onset was from May to October, i.e. peak summer months when the temperature ranges from 30[degrees]C and 45[degrees]C in India.

Discussion

The present study highlights the demographics of ATPD patients along with the variables associated with the onset of illness and their effect on its outcome.

Demographics and Outcome

The mean age of onset of ATPD in our sample was 27 years. The most common age-group (20-39 years) of our patients was more or less similar to that observed in other studies. (6, 9, 10) The mean age of onset was older in females (29 years) then males (27 years). Castagnini et al (11) also reported older age of ATPD onset in females than males, though the mean age of onset was higher than that in our patients. Of note, the mean age of ATPD onset seems to be later than the age of onset of schizophrenia, although reported ages of onset do vary. (10, 11)

In our study, patients younger than 20 years were slow responders and had relatively increased duration of hospital stay. Patients with onset of illness at or after the age of 20 years showed early response to treatment and, thus, had a favourable clinical outcome. This implies that, even though early adulthood is the most vulnerable period, the onset of ATPD in this age can predict an early treatment response. Furthermore, younger patients (< 20 years) might represent a subgroup of patients that is likely to develop major psychiatric illness in the long term.

In our study, more females than males were affected by ATPD (male-to-female ratio, 0.95:1). Similar to our findings, Susser and Wanderling (7) reported male-to-female ratio of non-affective acute remitting psychosis of 0.96 in developing countries. The female preponderance of ATPD has also been shown in several previous studies. (6, 11-13) The more common occurrence of ATPD in females distinguishes it from schizophrenia which has slightly higher incidence in young males. (14, 15)

More than half of our patients (68%) were married and 52% belonged to nuclear families. Marital status of the patients significantly affected the outcome of their illness, though the type of family did not. It may be argued that married patients had an early treatment response, as indicated by their shorter duration of hospital stay because of the important support from their spouses. The majority of patients was unemployed, and this group, predominantly, included housewives and students who were educated up to middle school. Occurrence of ATPD was more common in people from rural areas, similar to that reported in many Indian studies. (7, 16-18) Locality did not influence the outcome, probably because the number of urban patients was very small for correct inference.

Variables Associated with Onset and Outcome

More than half of our cases (54%) did not experience stress prior to onset of illness as opposed to the studies by Malhotra (19) and ICMR (6) which reported stress in almost 60% and 70% of the cases, respectively. However, studies in European countries reported 'acute stress' only in small number of cases. (12, 14, 20)

Fever was the most common event among those who experienced some precipitating stress just prior to onset of illness. Previous studies (16, 21, 22) have reported a significant association of fever with onset of acute psychosis in developing countries. This was attributed to the hormonal and biochemical changes in the brain due to fever, resulting in psychosis.

Of the 85 patients reporting a stressor prior to onset of illness, 56 (66%) were females. Malhotra et al (16) also found that stressful events were more commonly reported among female than male patients with non-affective acute psychosis.

We also studied the presence or absence of a family history of any psychiatric disorder in first-degree relatives of our cases as it determines the constitutional vulnerability of an individual for the disorder. Only one-fourth of our study population had a family history of psychiatric illness. This is in sharp contrast to findings of a previous Indian study (5) which reported a family history of psychiatric illness in a high proportion of patients of reactive acute psychosis. In another study, (23) the proportion of first-degree relatives with any mental disorder was higher in a group of ATPD patients compared with healthy controls.

Overall, 63% (27 of 43 cases) of patients with a family history of psychiatric disorders among first-degree relatives also had a stressor prior to onset of illness, thus, pointing towards the cumulative role of stress and constitutional vulnerability in causation of illness. Substance use was found in 50 (27%) cases. Nicotine was the most commonly used substance; 2 cases were using alcohol and 4 were using cannabis.

The majority of patients had DUI of 7 to 15 days. Those patients with DUI of < 7 days showed favourable outcome than those with longer DUI. According to Sajith et al, (9) abrupt or acute onset of psychotic episode was a predictor of favourable outcome in their study.

We found that the onset of ATPD was in summer in 54% of our cases, similar to the findings by Malhotra et al (16) who reported that onset of acute psychotic states tends to peak in summer months. However, it remains to be determined whether this association is attributable to the physical effects of the heat, neuroendocrine changes due to temperature, endogenous circadian rhythms or activation of some viruses at this temperature range predisposing to fever and subsequent acute psychosis. Since there are not much data on the month of onset of acute psychotic states, this finding remains inconclusive.

To the best of our knowledge, the sample size of our study is the largest among all the studies on ATPD in developing countries. This provides strength to the findings of our study though it was retrospective.

The major limitation of our study was that we assessed the outcome by a proxy measure and not by any standardised instruments. Although the information about patients was obtained from the most reliable informant (family member in most cases), the reliability of information could not be controlled due to the retrospective study design. Also, our study findings could not be generalised as the sample was drawn from a single centre.

Conclusion

Acute and transient psychotic disorders occur in both males and females, with slight preponderance in females. It is more common in early adulthood, and in the married, unemployed, and rural people. Age of onset and marital status had significant effect on the outcome. In most cases, the onset of illness was not associated with a prior precipitating stress, substance use, and a history of psychiatric disorder in first-degree relatives. Further research in this area is warranted as the understanding of the illness remains elusive.

Submitted: 10 July 2013; Accepted: 5 December 2013

Declaration

The authors declared no conflict of interest in this study.

References

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(2.) Wig NN, Singh G. A proposed classification of psychiatric disorders for use in India. Indian J Psychiatry 1967;9:158-71.

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(4.) Singh G, Sachdeva JS. Acute schizophrenic episodes: Are they schizophrenic? Indian J Psychiatry 1981;23:200-5.

(5.) Chavan BS, Kulhara P. A clinical study of reactive psychosis. Acta Psychiatr Scand 1988;78:712-5.

(6.) Indian Council of Medical Research. Final report of phenomenology and natural history of acute psychosis. New Delhi: ICMR; 1985.

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(22.) Collins PY, Varma VK, Wig NN, Mojtabai R, Day R, Susser E. Fever and acute brief psychosis in urban and rural settings in north India. Br J Psychiatry 1999;174:520-4.

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Dr Shubham Mehta, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Dr Alok Tyagi, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Dr Mukesh K Swami, MD, Department of Psychiatry, BPS Government Medical College for Women, Sonepat, Haryana, India.

Dr Suresh Gupta, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Dr Mahesh Kumar, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Dr Richa Tripathi, MD, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Address for correspondence: Dr Shubham Mehta, Department of Psychiatry, SMS Medical College, Jaipur, Rajasthan, India.

Tel: (91) 9467550100; Email: drshubhammehta@gmail.com

Table 1. Socio-demographic profile of study sample (n = 185).

Variable                             No. (%)

Age (years)
 <20                                 49 (26)
 20-39                               111 (60)
 [greater than or equal to] 40       25 (14)
Sex
 Male                                91 (49)
 Female                              94 (51)
Marital status
 Married                             126 (68)
 Unmarried                           57 (31)
 Divorced/widowed                     2 (1)
Occupation
 Unemployed (including housewives)   137 (74)
 Professionals                        2 (1)
 Farmers/labourers                   46 (25)
Education
 Illiterate                          44 (24)
 Up to middle school                 92 (50)
 Middle to secondary school          36 (19)
 Graduate/postgraduate                13 (7)
Monthly income (Rupees)
 <6000                               165 (89)
 6000-15,000                         18 (10)
 >15,000                              2 (1)
Religion
 Hindu                               172 (93)
 Muslim                               13 (7)
Family type
 Nuclear                             97 (52)
 Nuclear extended                     8 (4)
 Joint                               80 (43)
Locality
 Urban                               23 (12)
 Rural                               162 (88)

Table 2. Effect of socio-demographic variables on the outcome of
acute and transient psychotic disorders.

Variable                  Hospital stay   Hospital stay    [X.sup.2]
                             <7 days      [greater than    (degrees
                            (n = 104)     or equal to]     of freedom)
                                             7 days
                                            (n = 81)

Age (years)                                                7.70 (2)
 <20                           19              30
 20-39                         71              40
 [grater than or               14              11
   equal to] 40
Sex                                                        0.71 (1)
 Male                          54              37
 Female                        50              44
Marital status                                             6.79 (2)
 Married                       79              47
 Unmarried                     24              33
 Divorced/widowed               1               1
Occupation                                                 4.35 (2)
 Unemployed (including         74              64
   housewives)
 Professionals                  0               1
 Farmers/labourers             30              16
Education                                                  2.61 (3)
 Illiterate                    23              21
 Up to middle school           57              35
 Middle to secondary           18              18
   school
 Graduate/postgraduate          6               7
Monthly income (Rupees)                                    2.54 (2)
 <6000                         90              75
 6000-15,000                   12               6
 >15,000                        2               0
Religion                                                   0.58 (1)
 Hindu                         98              74
 Muslim                         6               7
Family type                                                0.61 (2)
 Nuclear                       52              45
 Nuclear extended               5               3
 Joint                         47              33
Locality                                                   0.001 (1)
 Urban                         13              10
 Rural                         91              71

Variable                  p Value

Age (years)                0.05
 <20
 20-39
 [grater than or
   equal to] 40
Sex                        0.40
 Male
 Female
Marital status             0.02 *
 Married
 Unmarried
 Divorced/widowed
Occupation                0.13 *
 Unemployed (including
   housewives)
 Professionals
 Farmers/labourers
Education                  0.46
 Illiterate
 Up to middle school
 Middle to secondary
   school
 Graduate/postgraduate
Monthly income (Rupees)   0.44 *
 <6000
 6000-15,000
 >15,000
Religion                   0.45
 Hindu
 Muslim
Family type               0.76 *
 Nuclear
 Nuclear extended
 Joint
Locality                   0.98
 Urban
 Rural

* Fisher's exact test.

Table 3. Factors associated with onset of acute and transient
psychotic disorders (n = 185).

Variable                No. (%)

Precipitating stress
 Present                85 (46)
 Absent                 100 (54)
Substance abuse
 Present                50 (27)
 Absent                 135 (73)
Family history
 Present                43 (23)
 Absent                 142 (77)
Duration of untreated
  illness (days)
 <7                     50 (27)
 7-15                   70 (38)
 >15                    65 (35)

Table 4. Effect of factors on the outcome of acute and
transient psychotic disorders.

Variable               Hospital stay   Hospital stay    [X.sup.2]
                          <7 days      [greater than    (degrees
                         (n = 104)      or equal to]   of freedom)
                                          7 days
                                         (n = 81)

Precipitating stress
 Present                    51              34          0.92 (1)
 Absent                     53              47
Substance abuse                                         0.40 (1)
 Present                    30              20
 Absent                     74              61
Family history
 Present                    26              17          0.41 (1)
 Absent                     78              64
Duration of                                             6.09 (2)
  untreated
  illness (days)
 <7                         34              16
 7-15                       32              38
 >15                        38              27

Variable               p Value

Precipitating stress
 Present                0.34
 Absent
Substance abuse         0.53
 Present
 Absent
Family history
 Present                0.52
 Absent
Duration of             0.05
  untreated
  illness (days)
 <7
 7-15
 >15
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Article Details
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Title Annotation:Original Article
Author:Mehta, S.; Tyagi, A.; Swami, M.K.; Gupta, S.; Kumar, M.; Tripathi, R.
Publication:East Asian Archives of Psychiatry
Article Type:Report
Geographic Code:9INDI
Date:Jun 1, 2014
Words:3288
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