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Indian Journal of Community Medicine

Use of SRQ in Psychiatric Epidemiology

Author(s): S.V. Chincholikar

Vol. 29, No. 4 (2004-10 - 2004-12)

Abstract

Research Question: Can Self Reporting Questionaire (SRQ) be used for screening of psychiatric morbidity?

Objective: To find out validity of SRQ.

Study design: Cross sectional study.

Participants: Blind people.

Study Variables: Sensitivity, Specificity.

Statistical analysis: Fishers Exact test

Methods: S.R.Q. was tested for screening of blind persons to detect psychaitric morbidity A score of cut off point equal to or more than 10 was considered as S.R.Q. positive subjects psychaiatric morbidity and less than 10 was considered as S.R.Q. negative subjects.

Results: There were 14 S.R.Q. positive cases. 12 S.R.Q. positive subjects and a double no. of matched S.R.Q. negative subjects were examined by qualified psychiatrists. Sensitivity and Specificity was found to be 92% and 83% respectively.

Conclusion: S.R.Q. can be used as screening technique for identifying probable psychiatric morbidity.

Keywords: S.R.Q., Psychiatric Morbidity, Specificity, Sensitivity

Introduction

Psychiatric research for decades was confined to mental hospitals and psychiatric clinics, and was characterised by lengthy interviews, case records, case studies. Application of public health principles to mental disorders was tried, with the aim of expanding the mental health research beyond the mental health hospital and the psychiatric clinics. It is at stage of implementation in field, that the difficulties in practicing these scientific principles are experienced. Resource crunch, especially in respect of technical manpower, poses the main hurdle among other things, especially in a developing country like India. It is generally agreed that psychological aspects are the common victims of these circumstances. A very substantial lack of manpower trained in psychology, psychiatry, social sciences and related fields has been the real hurdle in this respect.

In 1976, four studies were undertaken in developing countries by WHO in remote rural areas in India, Colombia, Senegal and Sudan to evaluate and effectiveness of alternative low-cost methods for providing mental health care in developing countries1. Various proforma used in these WHO studies were further modified and designed in a simpler and shorter form by Harding et al in 1980,2 which resulted in the currently used form of Self Reporting Questionnaire S.R.Q. that has been tested in various situations by indigenously conducted studies3-5. Therefore the present study was carried out in 2 institutions which have been carrying out vocational rehabilitation of blind persons for a long time. The research was undertaken with the objective to study the validity of the above-mentioned psychological screening technique.

Material and Methods

The study was conducted in two institutions from Jan 92 to Jan 93. These were Technical Training Institute of Blind Men, Poona Blind Men's Association, situated in Hadpasar, and The Poona School and Home for the blind girls situated near Kothrud. The respective authorities of above institutions admit blind subjects having inability to count fingers at a distance of 6 meters as certified by Civil Surgeon of the concerned district. Permission was obtained form respective authorities of above two institutions for conducting this study. All the blind enrolled in above two institutions at the time fo the study were included. Information was given to all blind included in the study about types of questions and answers were obtained by interview technique.

Self Reporting Questionnaire, consisted of 20 questions. Experience for scientific utilization of Self Reporting Questionnaire was obtained by working in the psychiatry department under the guidance of qualified psychiatrist. All S.R.Q. positive subjects and a double number of matched S.R.Q. negative subjects were examined by qualified psychiatrics for findings out psychiatric morbidities. S.R.Q. status of subjects was not made known to the examing psychiatrist.

S.R.Q. is designed as a screening tool for psychiatric morbidities and consist of 20 questions. It is to be answered by the subjects as affirmative or negative. The score in each case is represented by the total number of affirmative answers given by the subjects concerned. The cut off point for classifying the results into S.R.Q. positive was at the score of equal to or more than 10.

Results and Discussion

Fourteen (6.8%) subjects were SRQ positive. It was observed, that subject having psychiatric morbidity belonged to diagnostic categories of ICD - 10 classification of mental and behavioural disorders with morbidities such as disthymic disorder, mixedanxiety and depressive disorder, anxiety and dependent disorder and adjustment disorder6. Bansal et al7 in their study observed, that visually handicapped subjects showed high scores in the areas of depression and tension. Fitzegerald8 in this study found, that blind goes through phases of disbelief, protest, depression and finally recovery.

Two S.R.Q. positive cases could not be examined because of death in one case and failure to follow up in the other. Thus, total 36 blind, including 12 S.R.Q. positive and 24 S.R.Q. negative, were examined by psychiatrists. The S.R.Q. results were not made known to the examined psychiatrists.

Table I : S.R.Q. Results and Psychiatric Diagnosis

S.R.Q.Results Psychiatric Diagnosis Total
Morbidity Present Morbidity Absent
S.R.Q. Positive 10 (83.33%) 2 (8.33%) 12
S.R.Q. Negative 2 (16.67%) 22 (91.67%) 24
Total 12 24 36

When S.R.Q. results were co-related with psychiatric diagnosis there was statistically significant difference between the two at 95% confidence limit (P<0.001). This indicates that significantly high proportion of cases were conglomerated in true positive/ negative categories. Thus S.R.Q. results were good indicator of psychiatric morbidity. As revealed in the table I , 83.33% of S.R.Q. positive subjects were confirmed to be having psychiatric morbidity.

Using cut-off point 10, the sensitivity of S.R.Q. was 83% while specificity (was 91%. Table II) Similar were the results obtained by Chavan and Agahse5 in their study in which they used the same cut-off point. They observed, that association between S.R.Q. results and clinical diagnosis was statically significant at 95% confidence limit. The sensitivity was 83% and specificity was 85%. B. Sen et al3 in their study also observed similar results.

Jair De Jesus Mari and Paul williams4 also observed sensitivity of S.R.Q. at 83% and specificity at 80% in their study of validity of S.R.Q. 20 in primary care in city of Sao Paulo. S.R.Q. has been verified under various conditions in others studies, wherein, a score or 10 more was used as cut-off point. In order to confirm whether the same cut-off point serves the purpose when used for screening blind persons, an attempt was made to analyse the effect on senstivity and specificity when cut-off points varying from 1 to 20 were used.

Table II: Sensitivity and Specificity of S.R.Q. Using Differential Cut-Off Points

Cut-Off Points Sensitivity (%) (Approx.) Specificity (%) (Approx.)
1 100 46
2 100 58
3 100 62
4 91 67
5 83 75
6 83 79
7 83 83
8 83 83
9 83 83
10 83 91
11 75 91
12 66 91
13 66 95
14 66 95
15 57 95
16 50 100
17 41 100
18 41 100
19 41 100
20 18 100

Upto cut-off point 1-6 the sensitivity computed to be high, the corresponding specificity values were unaccepted low. Conversely, beyond the cut-off point 11, the sensitivity dropped to very low unacceptable levels. Keeping in mind, that S.R.Q. is meant as a screening test, if cut-off points upto 6 are utilized, there will be an unnecessary burden of false positive cases on already overworked psychiatrists. If cut-off points beyond 11 are employed, a large number of psychiatric morbidities are likely to be missed, as they will be screened out at the first phase.

Cut-off points 7 to 10 showed fairly high specificity values. Change from 7 to 10 did not affect sensitivity, but change from 9 to 10 brought the specificity from 83% to 91%. Thus a score of 10 was confirmed as the most suitable cut-off point with highest possible sensitivity - specificity - combination. It can, thus, be concluded, that S.R.Q. positivity at cut-off point 10 can be taken as an acceptable indicator of psychiatric morbidity.

S.R.Q. can be used for screening of probable psychiatric morbidities as this technique is simple, rapid and can be undertaken by non technical lower level functionaries and can give results within short span of time. Thus S.R.Q. can be the answer to perpetual manpower crunch in the area of psychiatry, as there is already substantial lack of psychiatist in our country.

References

  1. Harding T.W., Climent C.E., Giel R., Ibrahim, Murthy R.S. Suleman M.A., Wig N.N.,: W.H.O. collaborative study on strategies for expanding mental health care II. The development of New Research Methods. Amer J Psychiatry. 1983, 140.
  2. Harding T.W., de Arango M.V., Baltazar J., Climent C.E., Ibrahim H.H.A., Igansio L.L., Murthy R.S., Wig N.N.,: Mental disorders in primary health care. A study of their frequency and diagnosis in four developing countries. Psychological Medicine 1980; 231-241.
  3. Sen B, Williams P.: The extent and nature of depressive phenomenon in primary health care. Brit. J psychiatry, 1987; 451:406-449.
  4. Mari J.J. & Williams P.: A validity study of psychiatric screening questionnaires, (S.R.Q.-20) in the primary health care in the city of Sao Paulo, Brit. J psychiatry. 1986; 148:23-26
  5. Chavan D. & Agahse M.: Study of psychological status of patients admitted for a general hospital for attempted suicide. A dissertation submitted for Degree of M.D. - Br. IX, psychiatry. Examination of University of Poona, Dec' 1991, Unpublished personal communication.
  6. ICD 10, W.H.O.: Classification of mental and behavioural disorders 1992.
  7. Bansal R.K., Jain I.S., Kohli T.K., Bansal S.L. : Psychological factors associated with visual impairment. IInd J Psychiatry. 1980;22:173-175.
  8. Fitzergerald R.G.: Reactions of Blindness : An exploratory study of adults with recent loss of sight. Arch Gen. Psychiatry 1970;22:370-379.
  9. Park K.: Park's Textbook of Preventive and Social 13th edition Banarasi Das Bhanot Publication, page 443-445.

Department of P.S.M.,
M.I.M.E.R. Medical College,
Talegaon - Dabhade 410 507, Distt. Pune, Maharashtra

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