In the name of GOD The compassionate , the merciful

In the name of GOD The compassionate , the merciful

Iranian Rehabilitation Journal


Chairman : M.T. Joghataei, PhD Editor in Chief : M.Mirkhani , Ms Manager : R.Seyednour, MD Editorial Board : A.Dadkhah , PhD A.H.Sazmand , PhD A.Zarrabi , MD D.T. Wade , MD E. Helander , PhD H.Kakooyi , PhD H.Shemshadi , MD M.Fallahpour , Ms M.Mirkhani , Ms M.R.Nikou , MD M.R.Nourbakhsh , PhD M.Salavati , PhD M.T.Joghataei , PhD N.Hatamizadeh , MD N.Sadeghpour , Ms R. McConkey , PhD R.Nillipour , PhD R.Seyednour , MD R.Vameghi , MD S.M.E. Musavi , MD Y.Lotfi , MD.

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Vol 2 No.2

September.2004

I R J Iranian

Rehabilitation

Journal

CONTENTS

-Instructions to Authors

1

- Editor's Note

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- A Review on Occupational Therapy in IR.Iran M. Fallahpour . Ms

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- Hearing Impairments in Consanguineous Marriage Y. Lotfi . MD

9

- Rehabilitation of Schizophrenia : Adjunctive Therapy of Negative Symptoms . S. Shoja Shafti . MD

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- Stress Management and Health Promotion A. Dadkhah . PhD

26

- Children of Addicted Fathers H. Agha Bakhshi . PhD

34

II


Iranian Rehabilitation Journal Instructions to Authors

Iranian Rehabilitation Journal(IRJ) is published bi-annually by University of Social Welfare and Rehabilitation Sciences . It is a scientific multidisciplinary journal and concerns with disability issues and medical , social and Vocational Rehabilitation of any kind of disability including motor disorders , sensory defects ( vision and hearing ) and mental disabilities . Contribution from different professionals in Rehabilitation and reports in disabilities issues are welcome . The Editorial Board will consider leading , original and review articles for publication as well as book reviews and letters and introduction for innovative methods and procedures . General The contribution must be in English . Five quality copies of the manuscript ( MS ) should be submitted ; each with its full complement of tables and figures . The preparation of the manuscript with respect to layouts , typing , illustrations , including title page , and references must be according to the “ Uniform Requirements for Manuscripts submitted to Biomedical Journals . “

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Abstract The author(s) should start the manuscript with an abstract of not more than 200 words . Neither abbreviations nor references should be used in the abstract . The abstract should be written in a structured format , and should address the following points : objective(s) , design , sample size and sampling , interventions , results , conclusion(s) and recommendation(s) , and be followed by three to five key words . Permission to Reprint Whenever a manuscript contains material ( texts , tables , figures , charts , etc . ) which is protected by copyright , it is the obligation of the author to secure written permission from the holder of the copyright . Manuscript and a Copyright The manuscript submitted for publication must be the work of the author or authors submitting it and neither it , nor any similar work , should be under consideration for publication , or have been published elsewhere by for any other journal . All authors must sign a declaration to this effect , together with written consent to publish after amendment if necessary by the Editorial Board . The manuscripts accepted for publication become the 1

exclusive property of the IRJ and may not be reproduced elsewhere , wholly or in part , without the consent of the Editors . Publication of an MS does not imply the Editor's agreement with the statements or opinions expressed therein ; and the authors take the responsibility for these and also for the accuracy of the references cited . Manuscripts are only accepted for publication with the understanding that the authors will permit editorial amendments , though galley proofs will always be submitted to authors before being sent finally to the press . Address for Submission of Manuscript Contributors , worldwide , should submit their manuscripts for consideration for publication in the IRJ , to the : Editor in chief Iranian Rehabilitation Journal The University of Social Welfare and Rehabilitation Sciences . Tehran-IRAN Kudakyar St , Daneshjoo Blvd , Evin . Zip Code : 1985713831 Telefax : (0098) +21 - 2408923 Web : www.uswr.ac.ir/irj.htm Email : [email protected]

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Editor's note

W

elcome to the September edition of IRJ. In the last few months , we have received a number of emails and letters regarding the first edition , so thank you for the support and for the time and effort you have taken to write us. It all indicates your deep interest in promoting and developing this initiative. In the article of " USWRS at a glance " in the first edition , we must apologize that we have neglected the impressive Role of Dr. Mohammadi , the former head of Iranian welfare organization , in establishing and founding USWRS , a unique approach that equipped the Rehabilitation and Welfare system to an academic - scientific character. Fortunately , during these months , we had two important pieces of news concerning disabled people in our country . First , for the protection and promotion of the rights of disabled people , new comprehensive legislation was passed by the Islamic parliament . This law covers all the key areas such as access to physical environment which all governmental and public sectors must provide for their buildings and facilities . This should consider People with various types of disability . The municipality should consider barrier - free features as a standard requirement in designs and plans for all new constructions . Welfare organization has responsibility to expand rehabilitation services in medical , social , vocational and educational dimensions . The participation of disabled people and their families must be encouraged and private , charity and nongovernmental sectors should be used . Assistive devices and technologies should be provided at subsidised prices to different

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groups of disabled people. Pre-vocational and vocational skills training programs for people with disability mostly in mainstream settings must be expanded . Effective medical care should be provided through introducing supplementary insurance schemes for people with disabilities . In the area of employment active support should be provided through a variety of measures , such as , quota schemes , reserved employment for blind people, loans and grants for small businesses , and premium exemption and financial assistance to enterprises employing disabled people . For continuing education of disabled people , in addition to adequate access and support services , special concessions for university entrance examination will be provided and studying will be free of charge . The second piece of good news was that after several years of debate finally a historical decision was made by parliament to establish a " Ministry of Social Welfare ". Before organizing this ministry there were 28 GOs and NGOs which had responsibility for social security and welfare affairs but now according to this law all these different organizations will be integrated or at least their policies and planning will be coordinated by this ministry . The main function of this ministry in three broad areas : (1) social security on a contributory basis which covers retirement pension , unemployment , accident , incapacity benefit and health insurance , the beneficiaries are entitled to a basic level of services and in the case of requiring supplementary services the users must be assessed for it . Contributory benefits are those benefits which individuals , their employers and government have paid through national insurance. Payment of 3

contributory benefits is dependent on the individual having made sufficient contribution in the relevant period to qualify . (2) Welfare program. Benefit include a wide varity of support and assistance for poor families, vulnerable groups (old people and people who are sick or who have a disability and cannot support themselves or their families) , families without a guardian and bread winner. Income support for low income families support services for homeless and destitute people and others . It must be added that in welfare program, service provision will done in three dimensions: preventive, restorative intervention and supportive measures . (3) Relief and rescue activities , and service provision in natural disasters with help and support of the Red Crescent Society and expansion insurance services for such events . As I stated in the editorial in the first edi-

tion disability and rehabilitation are vast field and this Journal has the advantage of publishing articles from all disciplines related to disability and rehabilitation . Readers will find in this issue articles on variety of subjects such as : Hearing impairment in consanguineous marriage , occupational therapy in Iran, rehabilitation of schizophrenia , Stress management and rehabilitation , Children of addicted fathers . We on behalf of the IRJ Editorial Advisory Board members express our gratitude to the authors , reviewers and those who worked behind the scenes, for their cooperation , support and hard work . We very much welcome comments and suggestions from our readers. This will help us to improve the quality of this Journal .

Thank you Seyed Majid Mirkhani Editor - in chief

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A Review on Occupational Therapy in Iran Mandana Fallahpour Department of Occupational Therapy Iranian Research Center on Aging University of Social Welfare & Rehabilitation Sciences Abstract:

T

his article is a review on occupational therapy in Iran. Occupational therapy started in the Rehabilitation faculty of Iran Medical University as a BS degree in 1973 . About 2000 students were graduated in occupational therapy and are active in different parts of the country .They assist disabled individuals to achieve maximal independence . In this article, a summary of the history and educational structure of occupational therapy and job opportunities of graduates of this speciality in Iran is given.

University started to train experts and specialists in different rehabilitation branches, including occupational therapy, physical therapy and speech therapy at BS level. Also, the Rehabilitation Faculty of Beheshti Medical University and the University of Social Welfare and Rehabilitation Sciences (USWRS) started to educate students in 1987 and 1993 respectively. These universities now run BS and MS degrees . As there hasn't been PhD degree education available for occupational therapists, usually they have to study in foreign countries. Meanwhile , PhD course plan in occupational therapy is dealing with its final stage for confirmation process in Ministry of Health , and Medical Education .

Key words: Occupational Therapy / Educational Structure History: The discipline of occupational therapy in Iran dates back 33 years in 1971. Mrs. Yansen, an occupational therapist from the World Health Organization established an occupational therapy ward in Shafa Yahyaeyan rehabilitation hospital. She trained the first group of OTs under her direct supervision , they were qualified in OT as a the technicians but were not awarded degrees . In 1973 the Rehabilitation Faculty of Iran Medical Vol.2 - No.2

Educational Structure and Programs: The Occupational Therapy BS degree is offered to high school graduates who have passed the National University Entrance Examination and has studied the four year course of OT program. The program consists of 137 unit credits at BS level and 35 unit credits at Ms level in theory and clinical practice . The content of theory and practical units is based on a wide range of activities and consists of basic , specialty courses and clinical training. The basic courses include anatomy, neuroanatomy, neurophysiology, physiology, psychology , psychiatry , physiopathology and so on. The specialty courses include Activity of Daily 5

Living ( ADL ) , kinesiology and biomechanics, occupational therapy in different diseases ( such as physical , mental, psychologic , pediatric , geriatric ) , play therapy, splint designing and so on. The clinical trainings include physical dysfunctions ( such as orthopedic, neurologic ) , mental & psychologic disorders, mental retardation, children developmental disorders (such as cerebral palsy) and vocational rehabilitation. Clinical training courses are offered in rehabilitation centers related to the universities such as hospitals and clinics under instructors' supervision. Activity and Employment Fields of Occupational Therapists : Graduates of occupational therapy assist disabled individuals in different fields. Nearly 2000 occupational therapists are working in the country. The spectrum of their services is as follows: Physical dysfunctions are: Orthopedic Neurological Rheumatological Congenital Deficiency Psychological Disorders Disorders in children (cerebral palsy, developmental and congenital disorders) Mental Impairments (mental retardation, learning disabilities, autism) Aging (disorders and disabilities). Visual Handicap Auditory Handicap Vocational Rehabilitation Addiction Due to the wide range of activities, occupational therapists are employed in different centers and organization in Iran and perform educational, research and thera6

peutic activities. OT centers are as follows: - Hospitals related to Ministry of Health, and Medical Education - Vocational centers related to Welfare Organization - School of children with special needs related to Special Educational Organization. - Rehabilitation centers related to Red Crescent Organization. - Public clinics and educational therapeutic centers under supervision of universities - Private occupational therapy clinics - Daily rehabilitation centers (OT services for children and psychological patients) - Senior Citizen Centers (aging nursing homes) - Vocational rehabilitation centers . Features of Occupational Therapy : These ideas underpin the work of Occupational Therapy. 1. Using purposeful activities which can affect individual health. 2. Therapeutic goals are considered based on a holistic approach in which all aspects including physical, social, psychological and so on have to be taken into account. 3. Interpersonal relationships are important factors in the occupational therapy process. 4. Occupational therapy incorporates other medical courses in order to obtain maximal function in the patient . Tasks of the occupational therapist : The occupational therapist participates as a member of rehabilitation team in the therapeutic process planning so depending on the disabilities and field of activities ( physical , psychological , … ) and his / her role includes : Iranian Rehabilitation Journal

- physical evaluation based on occupational therapist standard test - psychological evaluation based on occupational therapist standard test - Evaluating the progress of patient - Vocational evaluation of physical handicapped - Vocational evaluation of psychological handicapped - Provide occupational intervention for promoting functional performances. - Improving independence of activities of daily living in patients - Providing and designing of assistive devices for patients according to their disabilities - Investigating the situation of home, job and educational environment in order to modify these places with patients disabilities - Instruction of patients who use orthoses, prosthesis and assistive devices - Counselling the patient's family regarding required instructions and occupational therapy Iranian Association of Occupational Therapy (IAOT) : The increasing number of occupational therapists and the necessity to share thoughts and opinions to improve services resulted in the foundation of IAOT. IAOT was established in 1989 and its activities started in 1992. The, Ministry of Interior approved it in 1994.

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The major purposes of IAOT are : - Introducing occupational therapy courses and their practical application - Improving the relationship between academic and research community and occupational therapists . - Strengthening cooperation between occupational therapists in academic centers and public and private sectors. - To help members to solve problems while considering their rights - Cooperating with scientific , educational, research and therapeutic centers such as Ministry of Health, and Medical Education and Ministry of Culture and Higher Education - Translating, publishing and distribution of news received from international communities, research results and scientific events of Iranian and foreigner researchers - Survey on occupational therapy affairs and presenting their results to related centers - Advocacy regarding different issues (educational , research, …) presented by ministers, institutions and governmental and non - governmental organization to IAOT - Evaluating the country's needs in respect of the number of occupational therapy graduates - Investigation in how to educate the public about prevention methods of handicaps and their rehabilitation - Cooperation with organizations, rehabilitation and scientific associations and the handicapped associations - Instruction of ethic criteria in rehabilitation and medicine societies. - holding conferences, educational and scientific seminars and publishing their relative documents The Iranian Association of Occupational

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Therapy has become a member of World Federation of Occupational Therapy in 2004. Address of Iranian Association of Occupational Therapy: P.O. Box 15875-6378 Tehran - Iran Website : www.irota.org E-mail : [email protected]

References: 1.Constitution of Iranian Association of Occupational Therapy, 1994. 2.Comprehensive guideline of Occupational Therapy, Iranian Association of Occupational Therapy, University of Social welfare and Rehabilitation Sciences, 2002. 3. Fundamental of rehabilitation, Joghattai M.& Nodehi A., University of Social welfare and Rehabilitation Sciences, 1993. 4. First seminar of modern rehabilitation, Rehabilitation Faculty of Iran Medical University, 15. 991.

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Hearing impairments in consanguineous marriage Younes Lotfi ,MD University of Social welfare and Rehabilitation Sciences Saeideh mehrkian Master degree in audiology Abstract:

Key words :

onsanguineous marriage is strongly favored in many large human populations. In the most parts of south Asia, consanguineous marriage account for 20% to over 50% of the general population . The effect of consanguinity on hereditary deafness has been well studied and documented. Many authors have suggested that approximately one half of sensory neural hearing loss in children can be attributed to hereditary causes. This research was carried out in Rehabilitation Deputy of welfare organization of Iran in seven provinces. 1352 infants and preschool aged children participate in this research. The prevalence of SNHL due to consanguineous marriage in first cousin and second cousin were studied. Consanguinity was found among 45.7 percent in first cousin and 17.2 percent in second cousin. Hereditary Factors were thought to be the cause of 863 (62.9 percent) of bilateral SNHL children in this research. The incidence of hereditary hearing impairment is very high in developing countries compared to developed countries . Prevention is essential to reduce the incidence of genetic hearing loss. Consanguinity should be discouraged and genetic counseling is to be applied at least for those at risk of developing genetic diseases including hearing impairments.

Consanguineous marriage, hearing impairmens , sensory-neural hearing loss

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Introduction : Consanguineous marriage occurs in varing degrees throughout the world. It is particularly prevalent in some part of Middle East, Asia, African and Latin American communities (1-2). In the most parts of south Asia, consanguineous marriage accounts for 20% to over 50% of the general population . The siblings of consanguineous marriages have a significantly higher incidence of hereditary disease including hearing impairments (4). The risks are greater, too, in families which have a genetic disorder in this case, marrying a relative can lead to a much higher risk of having an affected child. The great majority of hereditary deafness is caused by single autosomal recessive inheritance(5) .The effect of consanguinity on hereditary deafness has been well studied and documented. Many authors by using statistics principles and causes of deafness believe that consanguineous marriage will increase the chance of deafness by autosomal recessive genes. The purpose of this research was to study the prevalence of SNHL due to consanguineous marriage (the hereditary type) and to review the literature and the possi9

bilities of preventing or minimizing this custom. Material and Methods : In this research , 1352 infants and preschool age children, between ages 1 month to 6 years, were assessed during February 2001 to October 2002 . This study was performed in rehabilitation centers of Iran Welfare Organization (I.W.O ) in seven provinces ( Tehran , Esfahan, East Azarbayejan , Khorasan , Khoozestan , Mazandaran and Fars ) . All of children had bilateral symmetrical sensory - neural hearing loss. A questionnaire was prepared and completed with the help of the parents. It consisted of information regarding age, sex, consanguinity of parents, family history of deafness, hearing and speech deficits and exposure to various known risk factors for

10

hearing impairment. A child was considered to have hereditary hearing impairment if there was a positive family history. A sibling was considered as having a positive family history if a parental sibling of direct parent ancestors was deaf without environmental factors, regardless of the parental hearing status. Children with positive environmental factors (prematurely, hyperbilirubinemia, meningitis, rubella, etc) were considered to be deaf as a result of these factors.


Results : In this survey 1352 Cases , 50.9 percent male and 49.1 percent female, were evaluated , Table 1 shows the age and sex distribution of the children . Table 2 shows the relationship of the parents in each of provinces. In general the relationship of the parents were 631 (45.7 percent) in first cousin , 232 (17.2 percent) in second cousin and 501 (37.1 percent) in not related parents . The data in table 2 shows that consanguineous marriage between first cousin is much higher in Khoozestan rather than other provinces in Iran ( south of Iran ) .

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Hereditary factors were thought to be the cause of 863 ( 62.9 percent ) of bilateral sensory neural hearing loss. The prevalence of hearing impairment was founded to be significantly higher in the children whose parents were first cousins compared to the children whose parents were second cousins .

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Table 3 shows the degree of bilateral SNHL in children. 50.6 percent of children had profound hearing loss.

The prevalence of hearing impairment in the children and consanguinity of parents illustrate in figure 1 .

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Figure 2 shows frequency distribution percentile of total subjects according to consanguinity of parents.

Discussion : Consanguineous marriage is strongly favored in many large human populations . It can vary quite widely between and within countries, religions and cultural factors play a major part in determining social attitudes and legal frameworks at local and national levels. Some authors suggest such marriage should be avoided as they make double the risk of infants with birth defects such as mental retardation, deafness and blindness when compared with an "unrelated" marriage. Many authors have suggested that approximately one half of sensory neural hearing loss in children can be attributed to hereditary causes (6). In this study hereditary deafness accounted for 62.9 percent of 1352 children with bilateral sensory neural hearing loss. The parents of 17.2 percent children were second cousins and 45.7 percent were first cousins . Siraj Zakzouk (2002) reported 66.1 percent hereditary deafness in 168 children with sensory neural hearing loss in his first Vol.2 - No.2

study and 36.6 percent hereditary deafness in 142 in his second study. He had explained this big difference in the prevalence of hereditary deafness between the two samples was due to increased awareness of the families and the improved health services (7). Taylor et al. (1975) reported that most , if not all, cases of deafness previously classified as of "unknown cause" are cases of autosomal recessive inheritance (8). In the majority of cases of hereditary deafness (75 to 88 percent) inheritance is by a recessive single gene . Consanguineous marriage also increases the risk of transmission of polygenic (multifactorial ) inheritance . This uncommon type of inheritance is not fully understood, but it is postulated that multiple genes contribute to the disease and each individual has a threshold that about which the abnormality will be manifest (9). An important point is that for multifactorial inheritance, the risk to subsequent siblings is higher when the parents are consanguineous than when they are unrelated, in contrast to 13

autosomal recessive inheritance, where the risk is the same whether or not the parents are consanguineous .The effect of consanguinity on the development of childhood hearing impairment depend on the closeness of the relationship of parents. A marriage between first cousins poses a great risk, whereas a distant consanguinity has comparatively low risk of producing defective offspring, which is also supported by our findings. The hazards of blood marriage and the mechanisms that contribute to it must be explain for the families . Genetic counseling does provide those seeking information or advice a true picture of the situation with its associated risks , so the family can take the appropriate decisions about marriage. A preventive program is necessary to limit the number of children affected through public health education regarding the possible outcome risks of consanguineous marriage. Screening to identify carries of genetic disorders is an essential aspect of prevention. School screening , premarital, prenatal as well as neonatal screening should be part of the program .

reference to Northern Ireland, Ann Hum Genet 1956; 20: 177 - 231. 5- Smith RjH. Medical diagnosis and treatment of hearing loss in children. Otolaryngology head and neck surgery. St Iousis 1986; 4 : 3225- 46. 6- Brown KS. The genetic of childhood deafness. Deafness in childhood Nashville. TN, USA: Vanderbit University Press,1967; 177- 202. 7- Zakzouk siraj. Consanguinity and hearing impairment in developing countries : A custom to be discouraged. The journal of laryngology and otology . Oct 2002. Vol 116. 811-6. 8- Taylor IG, Hine WD, Brassier VJ, chiveralls K, Marris T.A. study of the causes of hearing loss in population of deaf children with special reference to genetic factors . J laryngol Otol . 1975: 89 ; 899915. 9- Northern JL, Downs MP. In : hearing in children . 2nd ed. Baltimor. MD, USA. William and Wilkins.Co. 1978.

References : 1- Kathy pick up. consanguineous marriages. what are the risks. Presentation in center of human genetics. Edith Cowan university perth western Australia , 2004 . 2- Castilla EE,Gomez MA, Lopez- Camelo JS, paz JE. Frequency of first cousin marriages from civil marriage certificates in Argentina. Hum Biol 1991 ; 63 : 203-10. 3- Murdoue GP-Ethnographic atlasPittsburgh, University of Pittsburgh Press. 1967. 4- Stevenson AC , Cheeseman EA , Hereditary deaf mutism with particular 14


Rehabilitation of Schizophrenia : Adjunctive Therapy of Negative Symptoms Saeed shoja shafti (MD) Assistant professor of psychiatry University of Social Welfare and Rehabilitation Sciences (USWRS) ABSTRACT : egative symptoms in schizophrenia are among the important barriers against psychosocial rehabilitation of such patients. Adjunctive drugs can be used for reducing the severity of these symptoms. In this research we studied the efficacy of Clomipramine, Alprazolam,Citalopram, Bromocriptine, Fluoxetine, Nortriptyline, Maprotiline and Fluvoxamine, in this regard. After a primary prevalence survey regarding Negative symptoms, 170 schizophrenic patients were divided into three different groups, and then the aforesaid adjuvant drugs were examined in three double-blind clinical controlled trials. Estimation of negative symptoms by "SANS" were done at the beginning of each trial for the first time and then three weeks later, after prescription of drugs in lower dosage and finally at the end of sixth week, means three weeks after doubling the dosages. The data were analyzed by z and chi-square (X2test) formula. Clomipramine, Alprazolam, Citalopram, Nortriptyline and Maprotiline could reduce the severity of negative symptoms. Their effectiveness in comparing with placebo was statistically remarkable. No important side effect or worsening of positive symptoms was seen in our samples during aforesaid trials.

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Conservative usage of adjuvant drugs can be an advantageous means for making rehabilitative programs more efficacious than before.

Introduction : Negative symptoms in schizophrenia as one of the major criteria in addition to other ones in DSM TV-TR, include six presentation as follows: 1)Restricted up to flat affect 2)Apathy 3)Alogia 4)Anhedonia 5)Avolition 6)Asociality (1,2). According to Carpenter existence of at least two of these symptoms or more for duration not less than twelve month is enough for diagnosis of deficit syndrome, as a subtype of schizophrenia (3). In DSM IV-IR, too, negative symptoms in addition to one of the positive symptoms (delusion, hallucination, disorganized speech, and disorganized behavior) for duration of at least one month is enough for diagnosis of acute phase. Anxiety, suspiciousness, mental retardation, depression, Parkinsonism and lack of environmental stimulants can result in secondary negative symptoms or reinforcement of primary ones. The importance of negative symptoms can be deduced also from the hidden firm barrier which is constructed by them between patients and others around them. Inaccessibility to patients which is resulted from such cluster of symptoms, after suppression of positive 15

symptoms, can make different psychosocial interventions, which are employed in the framework of community psychiatry, futile. This phenomenon especially in developing or nondeveloped countries can result easily to a kind of pessimistic and doubtful standpoints regarding the goals and efficiency of rehabilitation of such patients. Therefore if reducing the severity

among Iranian schizophrenic patients and 2) the effectiveness of adjunctive drugs on severity of such symptoms. Method and materials : RAZI psychiatric hospital, located in south of Tehran, the largest psychiatric

Table 1- Inclusion and Exclusion criteria

of negative symptoms by pharmacological strategies can facilitate the attainment of short and long term goals of rehabilitation, this will support the application of such programs with respect to the cost-effect economical points of view, which as a guarantee is not many times less important than academic or humanistic benefits. So there has been done a survey regarding 1) the prevalence of negative symptoms 16

hospital in middle East, and the first established center for handling psychiatric patients since last century in IRAN, had been chosen as our field for research. In summer of 2003, among one thousand and two hundred (1200) patients who were admitted there, 2/3 of them in long-term wards and 1/3 in short-term ones, 270 patients with diagnosis of schizophrenia, according to the DSM IV-TR criteria, had Iranian Rehabilitation Journal

been chosen randomly for a survey regarding to the prevalence of negative symptoms and their severity. In this regard some of the patients had been excluded due to some intervening factors(table 1). This cluster of symptoms had been estimated and registrated by Scale for Assessment of Negative Symptoms (SANS) (4). After determining this prevalence, they had been divided to three different groups . Group A ( n = 40 ) for a Clinical Controlled Trial ( CCT ) regarding the effectiveness of Clomipramine , Alprazolam , and Citalopram on reducing the severity of negative symptoms , Groups B ( n = 100 ) with a similar approach with respect to the moderating effect of Bromocriptine , Fluoxetine and Nortriptyline , and finally group C ( n = 30 ) regarding similar effects of Fluvoxamine and Maprotiline. In every group and at the beginning of the related trials , before addition any adjunctive drug , a new estimation of the negative symptoms by SANS had been performed as the baseline and then the adjunctive drugs had been a dded to the patient's current treatments , including typical antipsychotics ( one of the Chlorpromazine , haloperidol , Perphenazine Trifluperazine or Fluphenazine decanoate) . Each drug in each group was started with it's lower dose and then at the end of the third week after beginning adjunctive treatments , again another estimating of negative symptoms by SANS had been performed. Then the dosage of the aforesaid drugs had been doubled and after another three weeks the final severity of negative symptoms and their changing had been registrated . Overally grade 1, 2 and 3 were regarded as non-severe ( mild ) symptoms and grade 4 and 5 as severe. At the end, data had been Vol.2 - No.2

analyzed by Z and chi-square (X2-test) formula. All of the controlled trials had been done in a double-blind fashion and by the same team . Interview with the patients and their relatives , and also observations and remarks put forwarded by their nurses, social workers, psychologists and occupational therapists had provided the necessary resources for this research .

Results: The prevalence of negative symptoms among schizophrenic patients were remarkable . Almost no patient was free from negative symptom , and no specific or similar pattern could be found among them. Although some of the patients had similar severity in all of their negative symptoms , but many of them had discrete symptoms with different severity . The prevalence of Affecting Blunting , Alogia , Avolition-Apathy , AnhedoniaAsociality and finally Attention Deficit among this sample ( n=270 ) were : %96/28 ( n=260 ) , %94/80 ( n=156) , %99.62 ( n=269 ) , %98.88 (n=267) and %99.25 ( n=268 ) respectively .

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Table 2 - Prevalence of Negative symptoms among 270 schizophrenic patients in RAZI Psychiatric Hospital

( Table 2 ) . The age of these patients were between 24-68 years ( mean = 43.6 ) and the duration of their residency in hospital was between 2.5-28 years ( mean=17.83 ) and all of them were male. Then we selected forty (40) patients among them , as group A , for performing the first trial with Citalopram, Alpazolam Clomipramine and placebo, after dividing them into four subgroup, with every subgroup containing ten patients. The starting dose was 20mg, 0/75 mg , and 25 respectively for Citalopram , Alprazolam and Clomipramine which were doubled after three weeks . The whole of trial had been done accord-

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ing to the aforesaid processes in method and material's section . According to the resulted data , Citalopram ( p < 0/001 ) , Alprazolam (p