Content uploaded by Debasish Basu
Author content
All content in this area was uploaded by Debasish Basu on Feb 07, 2017
Content may be subject to copyright.
Reprinted from the German Journal of Psychiatry http://www.gjpsy.uni-goettingen.de ISSN 1433-1055
Mobile Phone Use by Resident Doctors:
Tendency to Addiction-Like Behaviour
Munish Aggarwal, Sandeep Grover, and Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Corresponding author: Dr Sandeep Grover, Assistant Professor, Department of Psychiatry, Postgraduate Institute of Medical
Education & Research, Chandigarh 160012, India; Email: drsandeepg2002@yahoo.com
Abstract
Background: There has been a revolution in the field of information and communication with the advent of multipur-
pose mobile phones. They have become an essential part of our life. However, concerns have been expressed regarding
the potentially adverse consequences of excessive mobile phone use as well, including its health, social and financial as-
pects. Aim of this study was to explore the pattern of mobile phone use among resident doctors and evaluate the same
using substance dependence criteria.
Methods: Resident Doctors were asked to complete a 23-item questionnaire, specifically designed for the present study
based on the ICD-10 dependence syndrome criteria and CAGE questionnaire.
Results: A total of 415 resident doctors were approached, out of which 192 responded. Eighty two percent of the resi-
dent doctors have been using mobile phone for more than five years and 72% of them have been using it for more than
an hour every day. Making and receiving calls was the main purpose of use among 90% of the resident doctors, fol-
lowed by texting and for using Internet services. Nearly forty percent of the participants fulfilled the ICD-10 substance
dependence criteria, while 27.1% of the subjects scored two or more on the CAGE questionnaire. Finally, 23.4% of
the subjects self-rated themselves to be “addicted” to mobile phones.
Conclusion: Of those with excessive use of mobile phones, some may be addicted to their use. This may impact the
work performance and the may have health consequences for them (German J Psychiatry 2012; 15(2): 50-55).
Keywords: mobile phone dependence, health consequence, prevalence
Received: 8.12.2011
Revised version: 17.5.2012
Published: 9.7.2012
Introduction
ankind has made tremendous technological ad-
vance over thousands of years from “Stone Age”
technology to the present day information tech-
nology. With the advent of newer technologies, the lives of
humans have become progressively easier. When a new
technology comes to the market, people have curiosity to use
that. In that curiosity some people tend to explore for more
and more benefits and end up using the same excessively
and resultantly exposing the negative consequences.
One of the important technological advancements in the last
three decades or so has been the advent of the mobile phone
(also known as cell phone). Over the last decade particularly,
due to availability of mobile phones to common people at a
reasonable price and considering its ever-increasing utility, it
is not surprising that mobile phones have become part and
parcel of the life of a common man for all ages (Ling &
Perdersen, 2005; Madell & Muncer, 2004; Mezei et al., 2007).
The various day to day uses of mobile phone include putting
reminders for important activities, playing games, using
calendar feature, setting up alarm (Alexander et al., 2007),
increasing awareness about certain things (for example,
having ring tones of vocalization of endangered species)
(Bryan et al., 2007), learning (for example, parents using the
mobile phones to teach their preschool wards learn alpha-
bets (Can Elmo Help Kids Learn Their ABCs?), a ready
source of camera for taking pictures in various situations,
some of which have been rare pictures or footages of vari-
ous calamities or joyful moments, accessing the Internet
M
ADDICTION-LIKE MOBILE PHONE USE
51
with its own multiple utilities, etc. With more and more use
of mobile phones by the younger generation, researchers
have evaluated the impact of the same on the life of the
users and have shown that use of mobile phone for social
networking and e-mail has helped to reduce loneliness (Oga-
ta et al., 2006) and in making friends (Kamibeppu & Sugiura,
2005).
However, data have now started emerging with respect to
the negative physical and psychological consequences of
excessive use of mobile phones as well. The International
Agency for Research on Cancer (IARC) (a branch of World
Health Organization) recently reported the possible in-
creased risk of development of brain tumors with excessive
use of some mobile phones, and the same has been reported
by other researchers too (Hardell & Carlberg, 2009; IARC,
2011). Also, there are concerns that use of mobile phone can
lead to impaired concentration, headache and dizziness
(Szyjkowska et al., 2005; Khan 2008), increased fatigue
(Khan 2008; Szyjkowska et al., 2005; van den Bulck 2007),
thermal sensation in and around the auricle, facial dermatitis
(Szyjkowska et al., 2005; Khan 2008), lack of sleep due to
night time use and frustration (Ogata et al 2006; Khan 2008).
A recent prospective study showed that at one year of follow
up, increased mobile phone use has been associated with
increased sleep disturbances in men and symptoms of de-
pression in both genders (Thomee et al., 2011). Also, elec-
tromagnetic radiations have been thought to affect the sleep
electroencephalogram (Loughran et al., 2005) and the mela-
tonin production (Wood et al., 2006). Mobile phone use
while driving has been associated with increased incidence of
road traffic accidents and this risk is present both for the
hand held and hands-free phones (McCartt et al., 2006;
Klauer et al., 2006).
Though the mobile phones are associated with the increased
freedom to communicate when and where a person wants
and increased accessibility to others, it makes a person com-
pelled to respond back immediately. It makes an individual
always available socially and takes away the social freedom
(Baron 2008). Mobile phones help parents to know the
whereabouts of the young wards when they are away, but at
the same time have made them to seek more rights and
freedom from parents (Ling 2004). The mobile phones have
become major source of managing social affairs but at the
same time excessive use of mobile phone is associated with
deterioration in the family life as one of the members attends
phone calls ignoring those involved in the face to face con-
versation (Hubbard et al., 2007).
In term of use of mobile phones in the health care system,
studies have shown these to be fast and effective means of
contacting the staff (Ramesh et al., 2008) and the negative
consequences linked to use of mobile phones are these being
a source of infection (Ramesh et al., 2008).
Considering the excessive use of mobile phone, some au-
thors have attempted to evaluate its dependence potential
and various questionnaires have been developed for the
assessment of problematic mobile use, psychological conse-
quences of mobile phone use and mobile phone addiction
(Dimonte & Ricchiuto, 2006; Beranuy et al., 2009; Rutland et
al., 2007; Chóliz & Villanueva, 2007; Toda et al., 2006;
Sanchez-Carbonell et al., 2008). Data suggest that majority of
the mobile addicts are teenagers, whose shyness and low
self-esteem make them succumb to aggressive publicity
marketing as a means to get in touch with people without
having to meet them (Takao et al., 2009). In one of the earli-
er studies the dependence symptoms that have been met
include excessive use in terms of economic cost and amount
of use, problems with parents due to excessive use, socio-
occupational dysfunction, psychological withdrawal and
tolerance (Choliz et al., 2009).
According to the recent statistics, India has the 2nd largest
mobile phone customer base, after China and the customer
base is expanding in India at a faster pace than that of China.
Studies from various parts of the world have shown adverse
physical and psychological consequences of excessive use of
mobile phones. However, no systemic study is available that
have evaluated the abuse and dependence potential of mo-
bile phone use in India.
In the recent times the concept of behavioral addiction has
gained the attention of researchers, and it has been evaluated
most commonly in relation to the Internet (Chakraborty et
al., 2010). Many efforts have been made to design question-
naires and diagnostic criteria for the same. The general drift
of the same is that the behavioral addictions have been un-
derstood as equivalent to substance dependence as under-
stood by the current nosological systems, while some others
have tried to understand behaviour addiction as more akin to
the obsessive compulsive spectrum.
Considering the increasing interest in behavioral addiction
and lack of data from India, the present preliminary study
attempted to explore the pattern of mobile phone use
among the resident doctors of a teaching hospital in North
India. The secondary aim was to evaluate their mobile use on
the International Classification of Disease, 10th edition (ICD-
10) Classification of Mental and Behavioral Disorders Crite-
ria of substance dependence syndrome (WHO 1992) and the
CAGE questionnaire (Ewing 1984; Ewing & Rouse, 1970;
Mayfield et al., 1974).
Methods
Resident doctors working in a large tertiary-care teaching
hospital in north India comprised the population. The sub-
jects were approached either in person or through e-mail by
purposive sampling. They were explained about the purpose
of the study. It was presumed that those who would respond
would provide implied consent to participate in the study.
A 23-item questionnaire was specifically designed for the
purpose of the study. The initial three items enquired about
the duration of use in years, time spent on mobile phones
per day and the main purpose of use. The other 20 items
were designed in such a way as to provide information about
the pattern of mobile use and whether such use fulfilled the
ICD-10 criteria for substance dependence syndrome and
substance dependence as per the CAGE questionnaire.
The frequencies and percentages were calculated for the
nominal data and mean and standard deviation was used to
AGGARWAL ET AL.
52
study the continuous variables. Associations between differ-
ent variables were studies by using Pearson product moment
correlation and Spearman rank correlations. Comparisons
were done using the Chi-square test. Kappa statistics were
used to evaluate the concordance between ICD-10 and
CAGE questionnaire.
Results
Of the 415 resident doctors contacted, 192 (42.26%) re-
sponded. Three fourth (76%) of them were males. Mean age
was 27.4 (SD-2.5; range 23-36) years and the mean duration
of mobile phone use was 6.1 (SD-1.96; range 1-14) years
with 92.7% using the same for 3 or more years and 82.2%
using the same for five or more years. The mean duration of
mobile phone use per day was 1.8 (SD-1.6; range 0.16 -10)
hours with 72.5% using the same for one or more hour per
day. All the participants used mobile phones for making and
receiving calls, 88% also used the short messaging services
(SMS), 56.2% also played games on their mobile phones,
68.2% listened to music on mobile phone, 49.5% also ac-
cessed internet through mobile phone and 77.6% used other
functions like organizer, alarm, camera etc.
When asked to report the most common purpose of mobile
phone use 88% of the subjects used phones most commonly
for making or receiving calls. This was followed by use of
SMS services (5.8%), using for Internet services (3.1%),
playing games (2.1%), and a few subjects described using
mobile phones most commonly for listening to music (0.5%)
and for other activities like clicking photos, setting alarm,
using as calendar, etc. (0.5%).
Responses to questions evaluating the mobile phone use
pattern have been shown in Table 1. The question “Do you
call back to most of the missed calls?” was the most com-
mon affirmatively answered (53.1%) closely followed by a
positive response (52.6%) to the question “Do you become
anxious of missing something if you have to switch off your
mobile phone for some reason?”
Based on the responses to the various questions, ICD-10
criteria were applied. For some of the criteria, responses to
more than one question were considered (see table-2) and in
such a scenario, if the participant answered in yes to one of
the questions, then it was considered that the participants
fulfills that ICD-10 criteria. Among the ICD-10 Diagnostic
criteria, most commonly met diagnostic criteria fulfilled was
Table 1. Questions assessing the mobile use pattern
Questions N (%)
13 Do you call back to most of the missed
calls? 102
(53.1%)
10 Do you become anxious of missing
something if you have to switch off
your mobile phone for some reason?
101
(52.6%)
16 Do you get irritated in the morning if
you are not able to locate your mobile
phone?
93
(48.4%)
14 Does using mobile phone help you to
overcome the bad moods (e.g. feeling
of inferiority, helplessness, guilt, anxie-
ty, depression etc.)?
86
(44.8%)
5 Has mobile phone use led to decrease
in meeting the friends in person 70
(36.5%)
19 Do you frequently participate in SMSs
or phone entry competitions? 6 (3.1%)
15 Do you feel guilty about the expendi-
ture on (or excessive use of) mobile
phone?
55
(28.6%)
20 Do you think you are getting addicted
to mobile use? 45
(23.4%)
6 Has mobile phone use has made you
spend less time with friends/ family 43
(22.4%)
11 Do you compulsively respond to calls/
SMSs at places which don’t permit
(Class, driving, group participation)?
41
(21.4%)
8 Do you lose track of time after starting
to use mobile phone for SMS, games,
music etc?
35
(18.2%)
17 Do your families/ friends/ colleagues
complain that your mobile phone use is
excessive?
35
(18.2%)
4 Do you get upset when attempting to
cut down mobile phone use? 34
(17.7%)
1 When not using the mobile, are you
preoccupied with the mobile phone
(Keep thinking about the previous and
the future uses)?
33
(17.2%)
7 Has mobile phone use has led to de-
crease in socialization? 33
(17.2%)
12 Do you compulsively respond to calls/
SMSs at places where it is dangerous
to do so (driving/ working at ma-
chines)?
29
(15.1%)
3 Have you made unsuccessful efforts to
control/ decrease or stop mobile phone
use?
27
(14.1%)
2 Do you need to use mobile phone for
increased amounts of time in order to
achieve satisfaction?
22
(11.5%)
18 Do you get annoyed or shout if some-
one asks you to decrease the use of
mobile phone?
22
(11.5%)
9 Do you lie to others to conceal the
extent of your use of mobile phone? 21
(10.9%)
Table 2. Number of participants meeting the ICD-10
diagnostic criteria
ICD-10 diagnostic criteria Participants
meeting the
criteria (%)
Intense desire (Q-1) 17.2
Impaired control (Q-3, Q-8, Q-11, Q-19) 41.7
Withdrawal (Q-10, Q-13, Q-16) 82.3
Tolerance (Q-2) 11.5
Decreased alternate pleasure (Q-5, Q-6,
Q-7, Q-17) 51.0
Harmful use (Q-12) 15.1
CAGE Questionnaire item
Cut Down (Q-7) 17.7
Annoyance (Q-18) 11.5
Guilt (Q-15) 28.6
Eye Opener (Q-16) 48.4
ADDICTION-LIKE MOBILE PHONE USE
53
that of withdrawal (82.3%), followed by neglect of alterna-
tive pleasure (51.0%) and impaired control (41.7%). A few
participants fulfilled the criteria of intense desire (17.2%),
harmful use (15.1%) and tolerance (11.5%). Overall 39.6%
of the participants met three or more of the ICD-10 diag-
nostic criteria for substance dependence.
Similarly the participants were evaluated on the CAGE crite-
ria based on the responses to one question for each con-
struct. About one-fourth (27.1%) of the participants had a
score of two or more on the CAGE questionnaire. Interest-
ingly, nearly one-fourth of the participants (23.4%) rated
themselves as being “addicted” to mobile phone.
When the level of agreement between ICD-10 and CAGE
questionnaire was assessed the level of agreement between
the two was low (0.31). The levels of agreement between the
self-rated addiction and ICD-10 dependence (0.38) and
CAGE questionnaire (0.32) responses were also low.
There was a significant positive correlation between duration
of use of mobile phone per day and harmful use criteria of
dependence on ICD-10 criteria (Spearman’s rank correlation
coefficient -0.168; p=0.023) and presence of dependence as
per ICD-10 criteria (Spearman’s rank correlation coefficient
-0.247; p=0.001).
There was no significant difference between the 2 genders
on the presence or absence or ICD-10 dependence and
fulfillment of 2 or more CAGE questionnaire items. In
terms of individual ICD-10 criteria, no significant difference
was noticed between males and females except that males
more frequently fulfilled the tolerance criteria (20 males
versus 1 female; Chi square value with Yate’s correction –
4.15; p=0.042).
Discussion
In the present study, the mean duration of mobile phone use
per day was 1.8 hours with 72.5% using the same for one or
more hour per day. This use appears to slightly excessive,
even after taking into consideration the fact that many of the
resident doctors are from far off places and use the phones
to keep in touch with their families and also use the same to
respond while on call duty. Besides using the mobile for
making and receiving phone calls, sending SMS and as-
sessing internet, which all may be part and parcel of profes-
sional requirement, 56.2% of the participants played games
on their mobile phones and more than two-third of them
also used mobile phones to listen to music on mobile phone.
These facts suggest that some of the doctors do use mobile
phones for non-essential things.
Some of the responses to the behaviour associated with
mobile phone use in the study participants can have im-
portant implications and these suggests that there is need to
study the mobile phone pattern along with assessment of
personality, interaction pattern with patients and fellow
doctors and health care outcomes. We would discuss some
of the responses, which can have important consequences.
About half of the participants responded that switching off
the mobile phones for some reasons causes anxiety. This can
have important health care and training complications. For
example, if a doctor has to switch off his mobile phone so as
to avoid getting distracted while conducting some procedure
on a patient, this itself may be distressing to the doctor and
would distract him from the procedure and may force him to
complete the procedure as soon as possible and may lead to
poor health care outcomes. Similarly from training point of
view it may disturb their concentration in the class. Nearly
45% of the doctors responded that they used mobile phones
to overcome bad moods, like feelings of inferiority, helpless-
ness, guilt, anxiety, depression etc. This suggests that these
feelings are very common in the resident doctors, which can
again have its implications on the life of the doctors and
outcome of the procedures and services rendered by them.
Another alarming fact was that in about one-third of the
doctors use of mobile phones was making them cutoff from
friends. Similarly about one-fifth reported that their friends
and family do complaint about the extent of their mobile
phone use and they lose track of time. All this can have its
own consequences in terms of managing team work effec-
tively, providing support to each other at the time of stress,
seeking and providing companionship to each other.
Again about-fifth of the doctors were using mobile phones
at places where they are usually required not to respond.
This can also have important personal, training and render-
ing health services.
All these suggest that there is an urgent need to carry out
detailed research in the area of pattern of mobile phone use
by the doctors and the adverse consequences/outcomes of
the same. Based on the finding of the same appropriate
guidelines need to be formulated for the mobile phone use
and the doctors needs to be made aware of the negative
professional consequences of their mobile phones.
Depending on the various definitions (self-evaluated, ICD-
10, CAGE), about one-fourth to two-fifth of the doctors
had features suggestive of dependence. However, these
figures should not be taken as true prevalence, because in the
present study, no distinction was made about the essential
and non-essential use of mobile phones. However, these
findings do suggest that excessive mobile phone use also
should be looked from behavioural addiction point of view
and specific criteria should be formulated for the same.
This study has many limitations. Being a preliminary study, it
was based on self-rated questionnaire with dichotomous
yes/no responses. The sample was not random. The re-
sponse rate was rather low. Further we did not evaluate the
personality, psychiatric morbidity, stress levels etc. Hence
some of the usage of the mobile phones as reported affirma-
tively by some of the subjects may be actual consequence of
these variables rather than reflective to true excessive non-
essential use of mobile phones. Further the study included a
relatively young group, with a relatively high educational
level cannot be generalized to the normal population.
AGGARWAL ET AL.
54
References
Alexander E, Ward CB, Braun CK. Cell phone attachment: a
measure and its benefits. Proceedings of the IABE-
2007 Annual Conference; Las Vegas; III, Number 1,
2007: 407-412.
Baron NS. Always on: Language in an online and mobile
world. New York: Oxford University Press 2008.
Beranuy Fargues M, Chamarro Lusar A, Graner Jordania C,
Carbonell Sánchez X. Validation of two brief scales
for Internet addiction and mobile phone problem
use. Psicothema 2009;21:480-5.
Bryan, SM. Call of the Wild, Marketing News 2007; March
15, 2007, 21.
Can Elmo Help Kids Learn Their ABCs? T H E Journal
2006; 33:17, 8.
Chakraborty K, Basu D, Vijaya Kumar KG. Internet Addic-
tion: Consensus, controversies, and the way ahead.
East Asian Arch Psychiatry 2010; 20:123-132.
Choliz M, Villanueva V, Chóliz M, C Ellos, ellas y su móvil:
uso, abuso (¿y dependencia?) del teléfono móvil en la
adolescencia (Girls, boys and their mobile: use, abuse
(and dependence) of the mobile phone in adoles-
cence). Revista Española de drogodependencias
2009; 34: 74–88.
Chóliz M, Villanueva V. Questionnaire of Dependence of
Mobile Phone: psychometric properties and gender
differences. 11th European Congress of Psychology.
Oslo, 7–10 July 2009.
Dimonte M, Ricchiuto G. Mobile phone and young people.
A survey pilot study to explore the controversial as-
pects of a new social phenomenon. Minerva Pediatr
2006;58:357-63
Ewing JA, Rouse BA. Identifying the hidden alcoholic. Pre-
sented at the 29th International Congress on Alcohol
and Drug Dependence. Sydney, Australia 1970, Feb
3.
Ewing JA. Detecting Alcoholism: The CAGE Question-
naire. JAMA 1984; 252:1905-1907.
Hardell L, Carlberg M. Mobile phones, cordless phones and
the risk for brain tumors. International journal of on-
cology 2009;35:5-17.
Hubbard A, Han HL, Kim W, Nakamura L. Analysis of
mobile phone interruptions in dating relationships: A
face threatening act. Paper presented at the Annual
Conference of the International Communication As-
sociation, San Francisco, CA, May 24-28, 2007.
IARC, 2011. Available from URL http://www.iarc.fr /en/
media-centre/pr/2011/pdfs/ pr208_E.pdf. Accessed
on 13.06.2011.
Kamibeppu K, Sugiura H. Impact of the Mobile Phone on
Junior HighSchool Students' Friendships in the To-
kyo Metropolitan Area. Cyberpsychol Behav 2005;
8:121-130.
Khan MM. Adverse effects of excessive mobile phone use.
Int J Occup Med Environ Health 2008; 21:289-93.
Klauer SG, Dingus TA, Neale VL, Sudweeks JD, Ramsey
DJ. The impact of driver inattention on near-
crash/crash risk: An analysis using the 100-car natu-
ralistic driving study data. DOT HS 810 594. Wash-
ington, DC: National Highway Traffic Safety Admin-
istration 2006.
Ling R. The mobile connection: The cell phone’s impact on
society. San Francisco: Morgan Kaufmann 2004.
Ling RR, Perdersen PE. Mobile Communications: Re-
Negotiation of the Social Sphere (Computer Sup-
ported Cooperative Work). London: Springer Verlag,
2005.
Loughran SP, Wood AW, Barton JM, Croft RJ, Thompson
B, Stough C. The effect of electromagnetic fields
emitted by mobile phones on human sleep. Neu-
roreport 2005;16:1973-6.
Madell D, Muncer S. Back from the beach but hanging on
the telephone? English adolescents' attitudes and ex-
periences of mobile phones and the internet. Cy-
berpsychol Behav 2004;7:359-67.
Mayfield DG, McLeod G, Hall P. The CAGE questionnaire:
Validation of a new alcoholism screening instrument.
Am J Psychiatry 1974; 131:121-123.
McCartt AT, Hellinga LA, Bratiman KA. Cell phones and
driving: review of research. Traffic Inj Prev
2006;7:89-106
Mezei G, Benyi M, Muller A. Mobile phone ownership and
use among school children in three Hungarian cities.
Bioelectromagnetics 2007; 28:309-15.
Ogata Y, Izumi Y, Kitaike T. Mobile-phone e-mail use,
social networks, and loneliness among Japanese high
school students. Japanese Journal of Public Health
(Nippon koshu eisei zasshi) 2006;53:480-92.
Ramesh J, Carter AO, Campbell MH, Gibbons N, Powlett
C, Moseley H Sr, Lewis D, Carter T. Use of mobile
phones by medical staff at Queen Elizabeth Hospital,
Barbados: evidence for both benefit and harm. J
Hosp Infect 2008; 70:160-5
Rutland JB, Sheets T, Young T. Development of a scale to
measure problem use of short message service: The
SMS problem use diagnostic questionnaire. Cy-
berpsychol Behav 2007;10: 841-843.
Sanchez-Carbonell X, Beranuy M, Castellana M, Chamarro
A, Oberst U. Internet and cell phone addiction: pass-
ing fad or disorder? Adicciones 2008; 20:149-59.
Szyjkowska A, Bortkiewicz A, Szymczak W, Makowiec-
Dabrowska T. Subjective symptoms related to mobile
phone use--a pilot study. Polski Merkuriusz Lekarski
2005;19:529-32.
Takao M, Takahashi S, Kitamura M. Addictive personality
and problematic mobile phone use. Cyberpsychol
Behav Soc Netw 2009; 12:501-7.
Thomee S, Harenstam A, Hagberg M. Mobile phone use and
stress, sleep disturbances, and symptoms of depres-
sion among young adults - a prospective cohort
study. BMC Public Health 2011;11:66-76.
Toda M, Monden K, Kubo K, Morimoto K. Mobile phone
dependence and health-related life-style of university
students. Soc Behav Pers 2006; 34:1277–84.
Van den Bulck J. Adolescent use of mobile phones for call-
ing and for sending text messages after lights out: re-
ADDICTION-LIKE MOBILE PHONE USE
55
sults from a prospective cohort study with a one-year
follow-up. Sleep 2007; 30:1220-3.
Wood AW, Loughran SP, Stough C. Does evening exposure
to mobile phone radiation affect subsequent melato-
nin production? Int J Radiat Biol 2006;82:69-76.
World Health Organization. The ICD-10 Classification of
Mental and Behavioural Disorders. Clinical descrip-
tions and diagnostic guidelines. Geneva: WHO, 1992.
The German Journal of Psychiatry ISSN 1433-1055 http:/www. gjpsy.uni-goettingen.de
Dept. of Psychiatry, The University of Göttingen, von-Siebold-Str. 5, D-37075 Germany; tel. ++49-551-396607; fax:
++49-551-398952; E-mail: gjpsy@gwdg.de
