Proxy consultations for severe mental illnesses: An exploratory cross-sectional study from a tertiary care hospital.

BACKGROUND: Non-adherence to medication leading to a break in continuity of care poses significant challenges in severe mental illness (SMI), leading to poor outcomes. In India, proxy consultation, wherein caregivers consult on behalf of patients, is a commonly adopted but insufficiently researched area to address these challenges. AIMS: To explore the extent of proxy consultation in outpatient care of persons with SMI and investigate its sociodemographic and clinical correlates. METHODOLOGY: In a tertiary care psychiatry outpatient setting, we conducted a cross-sectional study involving 374 caregivers of persons with SMI (Schizophrenia, Bipolar and related disorders). Descriptive statistics and univariate logistic regression were performed to examine correlates' relationships with proxy consultation. RESULTS: Proxy consultation prevalence was 43% in the past 1 year. Compared with 18 to 30 years, middle-aged patients aged 31 to 40, 41 to 50 and 51 to 60 years had twofold, threefold and sixfold increased chances of proxy consultation, respectively. Being illiterate had six times higher odds than graduates, three times and two times if they studied till primary and secondary education. Early age of onset was associated with three times higher chances of proxy consultation compared to the onset of illness in adulthood. On the contrary, male gender and upper and middle socioeconomic status decreased the chances of proxy consultation by 40%. Financial difficulties (n = 72, 45%) and patients' unwillingness to visit outpatients (n = 44, 27.5%) were the most commonly cited reasons for proxy consultation. CONCLUSION: Proxy consultations are relatively common, driven by many social, economic, patient-related, pragmatic and practical factors. In formulating community care policies for persons with SMI, the primary imperative should be to conduct additional research, deepening our understanding of proxy consultations. Additionally, it is essential to be mindful of the diverse issues associated with proxy consultations during the formulation process.

COMMENTARY: The Consumer Protection Act, 2019: A critical analysis from a medical practitioner's perspective.

The landmark judgment in the case of Indian Medical Association v VP Shantha in 1995 brought the medical profession under the ambit of the Consumer Protection Act, 1986. The Consumer Protection Act, 1986, was later repealed and replaced by the Consumer Protection Act, 2019. This article delves into the implications of the 2019 Act, highlighting significant changes in its scope, including the expansion of the definition of "consumer" and the incorporation of telemarketing and e-commerce within its ambit. Moreover, the amendments affect pecuniary jurisdiction, grounds for litigation, and introduce mediation cells, and the Central Consumer Protection Authority (CCPA). This article underscores concerns related to an increase in frivolous cases against medical practitioners and in defensive practice, ultimately impacting the overall quality of patient care. Recommendations for timely redressal and safeguards against unwarranted litigation are proposed to mitigate the adverse implications of the amended Act and ensure the well-being of both healthcare providers and patients.

Clinical Profile, Course and Outcomes of Male Inpatients with Mental Illness Charged with Homicide: A Chart Review from an Indian Tertiary Care Hospital.

Background: The relationship between imprisonment and mental illness is bidirectional. The clinical outcomes of prisoners with mental illness have not been widely studied, especially in developing countries. This study was conducted to assess the same among male inpatients under judicial custody with charges of homicide. Methods: A retrospective chart review of male forensic ward inpatients admitted between January 1, 2003, and December 31, 2016, was conducted. Diagnosis in the files was based on the International Classification of Diseases (ICD)-10 criteria. The Clinical and Global Improvement-Severity (CGI-S) scale was used to measure the severity of illness. Mean CGI-S assessment was carried out at baseline, end of 1 year, 5 years, and 15 years. The data were analyzed using descriptive statistics, Friedman's test, and Dunn's post hoc test. Results: Schizophrenia spectrum disorders and other psychotic disorders, mood disorders, and alcohol use disorders were diagnosed in 62(49.6%), 22(17.6%), and 44(35.2%) subjects, respectively. Forty-one (32.8%) subjects had at least one readmission. The average CGI-S score for the total subjects was 5 (markedly ill) at baseline and 2 (borderline ill) at the end of their latest contact with the tertiary care hospital. For the 34 subjects (27.2%) who had follow-up information of 15 years, the average CGI-S score was 1 (normal, not at all ill) at the end of 15 years (P < 0.001). Conclusion: Clinical outcomes of prisoners with mental illness seem promising, subject to the seamless availability of services. Studies from other parts of the country are required for a more systematic understanding of the requirements of care.

Study on covert administration of medications practices among persons with severe mental illness: A cross-sectional study.

BACKGROUND: Covert administration of medication (CoAdM) by caregivers to persons with severe mental illness (SMI) is a commonly observed medication delivery practice in India. AIMS: This study aims to examine different medication delivery practices adopted by caregivers to provide care to SMI at times of medication refusal. METHOD: This study was conducted at the outpatient department between April 2019 and November 2019. A semi-structured questionnaire was used to interview the caregivers of persons with SMI to assess medication delivery practices. RESULTS: A total of 300 caregivers were interviewed. CoAdM was practiced in 96 (32.0%) persons with SMI at least once during their lifetime, and other strategies used were pleading (n = 105, 35.0%), lying (n = 10, 3.3%), and threatening (n = 154, 51.4%). Logistic regression showed that male gender (OR 4.75; CI 1.37-16.46), absent insight (OR 10.0; CI 2.01-47.56), and poor adherence to medication (OR 4.75; CI 1.31-16.92) were significantly associated with CoAdM in the last 1 year. Caregivers perceived significant improvement in self-care (Z = -4.37, p < .01), interpersonal (Z = -7.61, p < .01), work (Z = -5.9, p < .01), family functioning (Z = -7.82, p < .01) difficult behavior (Z = -8.27, p < .01), and dependency (Z = -6.34, p < .01) in persons with SMI with use of CoAdM. CONCLUSIONS: CoAdM was given to one in three persons with SMI at some point in their lives. Male gender, absent insight and poor adherence were predictive of CoAdM in the last 1 year. Caregiver perceived improvements in self-care, work, interpersonal, family functioning, problem behaviors, and dependency after CoAdM. Policies need to be evolved to serve all stakeholders while keeping these practices in mind.

Bipolar affective disorder in India: A multi-site population-based cross-sectional study.

Introduction: Bipolar Affective Disorder (BPAD) merits careful consideration within the medical and healthcare communities, researchers, and policymakers. This is due to its substantial disability burden, elevated prevalence of co-morbidities, heightened lifetime risk of suicidality, and a significant treatment gap. This article focuses on the lifetime and current prevalence, correlates, co-morbidities, associated disabilities, socio-economic impact, and treatment gap for BPAD in the adult population of the National Mental Health Survey (NMHS) 2016. Materials and Methods: The NMHS 2016 was a nationally representative study conducted across 12 Indian states between 2014 and 2016. A multi-stage, stratified, random cluster sampling technique based on probability proportionate to size at each stage was used. The diagnosis of BPAD was based on Mini-International Neuropsychiatric Interview 6.0.0. Sheehan's Disability Scale was used to assess the disability. Results: A total of 34,802 adults were interviewed. The overall weighted prevalence of BPAD was 0.3% [95% confidence interval (CI): 0.29-0.31] for current and 0.5% (95% CI: 0.49-0.51) for lifetime diagnosis. Male gender [odds ratio (OR) 1.56] and residence in urban metropolitans (OR 2.43) had a significantly higher risk of a lifetime diagnosis of BPAD. Substantial cross-sectional co-morbidities were noted as per MINI 6.0.0 with the diagnosis of current BPAD such as tobacco use disorder (33.3%), other substance use disorders (14.6%), and anxiety disorders (10.4%). Two-thirds of persons with current BPAD reported disability of varying severity at work (63%), social (59.3%), and family life (63%). The treatment gap for current BPAD was 70.4%. Conclusion: Most individuals with current BPAD reported moderate-severe disability. There were substantial co-morbidities and a large treatment gap. These warrant concentrated efforts from policymakers in devising effective strategies.

Free legal aid in hospitals for persons with mental illness: Is it helpful? An Indian prospective study.

Background: Legislative backing exists to set up free legal aid clinics in psychiatric hospitals to provide legal assistance to their patients. Aims: This study aimed to assess the utility of a free legal aid clinic running inside a mental health establishment. Methods: In this prospective study, 71 subjects (chosen via convenience sampling) were recruited. Assessments were carried out at baseline and two months after intake. Legal needs and the legal outcomes were assessed. Results: Most of the legal issues were either family-related (50.7%) or civil issues (28.2%). A majority of patients (64.4%) had implemented the advice given at the clinic. Those who had implemented the advice had a better legal outcome, defined as either resolution of the legal issue or that the legal issue was in an active proceeding compared to those who had not implemented the advice (P = 0.007). Conclusion: The provision of free legal aid services in mental health establishments would benefit patients.

Perceived Barriers in the Assessment and Management of Female Sexual Dysfunction: a Survey Among Resident Trainees in Psychiatry.

OBJECTIVE: The authors examined the perceived barriers in the assessment and management of female sexual dysfunction among resident trainees in psychiatry. METHODS: An online survey was conducted among 148 resident trainees in psychiatry at a tertiary academic psychiatry center in India. It consisted of nine items with responses rated on a Likert scale. The anonymity of the responses was maintained. RESULTS: A total of 73 residents (49.3%) responded to the survey. Spontaneous reporting of sexual functioning, which is patient-driven, and spontaneous inquiry, which is resident-driven, were lacking. Specific barriers identified in the majority were lack of time, privacy, linguistic challenges, limited knowledge, and sociocultural background of the patient. The gender of the resident was not perceived as a major barrier in a majority. Marital discord appeared as a common response for inquiries into sexual functioning, while the use of psychotropics, the presence of medical comorbidities, and the postmenopausal state did not attract a majority to inquire about the same. Furthermore, a response that there was a lack of intervention in those reporting sexual dysfunction was commonly noted. Only 5.5% of the participants reported having received adequate formal training in the management of female sexual dysfunction. CONCLUSION: Female sexual dysfunction is common, adds to psychiatric morbidity, and affects the quality of life. It is important to impart training on female sexual dysfunction as a part of their residency program with cultural appropriateness. A future direction would be to evaluate the effectiveness of a formal training program for assessing and managing female sexual dysfunction.

Palliative Care and Legal Issues in Geriatric Psychiatry.

There is an increased risk of debilitating illnesses that often have no curative treatment with aging. The mainstay of treatment in many such conditions is palliative care: a holistic approach focused on preventing and relieving physical, psychosocial, legal, ethical, and spiritual problems. It involves the facilitation of end-of-life care decisions aimed at relieving distress and improving quality of life. In this article, the authors discuss the role of mental health professionals in legal issues related to palliative care in the elderly around decision-making, right to autonomy, euthanasia, and advanced directive. The cognitive decline associated with aging and mental health issues in the palliative care setting of an individual such as dementia, depression, and hopelessness, and impact on the family members like burnout may influence the overall capacity of that individual to make decisions about their treatment. While an individual has a right to self-determination and autonomy, withholding or withdrawing treatment has many legal and ethical implications, more so in those with incapacity, especially in India due to the absence of uniform legislation. The decision to withhold or withdraw treatment might be a restrictive choice due to limited options in a setting with a lack of palliative care options, poor psychosocial support, nonaddress of mental health issues, and lack of awareness. As the right to health is a constitutional right, and the right to mental health is legally binding under Section 18 of the Mental Health Care Act 2017, systematic efforts should be made to scale up services and reach out to those in need.

Civil responsibility in Geriatric Psychiatry.

Mental health issues impair decision-making capacity, more so in elderly people. Impaired decision-making capacity can make person unfit to enter into various civil deeds and agreements. Such civil deeds can include guardianship, property transaction, holding a bank account, having voting rights, making a will, donating an organ, etc. This article focuses on importance of mental health in entering into above-mentioned civil agreements, how to do assessments to determine if one is fit to enter into civil agreements, and what are the legal ways in which a person can avail help to execute his/her civil rights even when affected by mental health issues.

Free legal aid for persons with mental illness and other marginalized group of population.

The marginalized and vulnerable population like those with mental illnesses and other disabilities, senior citizens, disaster victims and women are at risk of facing violation of their rights. To preserve the rights of the above-mentioned vulnerable groups, Government of India has passed a legislation named Legal Services Authority Act, 1987. In this article authors discuss the interconnection between mental illness and rights violation, how Legal Services Authority Act, 1987 is relevant in preserving rights of persons with mental illness and other vulnerable groups, different programs under the above legislation, the provisions under those programs and how to obtain them.

Cultural competency training for psychiatry residents and mental health professionals: A systematic review.

INTRODUCTION: Cultural competence is a prerequisite skill for a psychiatrist. There is a dearth of information on the methods used for training of cultural competence and their outcomes. This study aims to explore and determine the existing methods used for cultural competency training (CCT) for psychiatry residents and how useful these training methods are. METHOD: A systematic review methodology based on PRISMA guidelines was adopted for this study. The literature search reviewed databases of PubMed and MesH, using keywords 'psychiatry resident', 'psychiatry', 'psychiatrist', 'mental health', and 'mental health professional'. In the end,14 articles qualified for the detailed review. The level of evidence and quality of the studies were evaluated and recorded. RESULTS: The methods of cultural competence training identified were grouped as, active/passive/mixed; group training/individual training. These included documentaries or non-feature films based teaching, secondary consultation and cross consultation models, case vignette discussions, Objective Structured Clinical Examination (OSCE), behavioral simulation, video demonstration, cultural discussion in rounds, and traditional clinical teaching. The studies covered participants from different cultural backgrounds, mainly urban and predominantly university/institution based. CONCLUSION: There is limited literature in the area to conclude one method to be better than the other with respect to CCT in psychiatry residents. However, this review identified a variety of training methods, which can be used and pave way for research on their effectiveness. Training and evaluation of psychiatry residents in the area of cultural competence should be done routinely during their training to enable them to practice in the multi ethic societies.

Digital Gaming Interventions in Psychiatry: Evidence, Applications and Challenges.

Human evolution has regularly intersected with technology. Digitalization of various services has brought a paradigm shift in consumerism. Treading this path, mental health practice has gradually moved to Digital Mental Health Interventions (DMHI), to improve service access and delivery. Applied games are one such innovation that has gained recent popularity in psychiatry. Based on the principles of gamification, they target psychosocial and cognitive domains, according to the deficits in various psychiatric disorders. They have been used to deliver cognitive behaviour therapy, cognitive training and rehabilitation, behavioural modification, social motivation, attention enhancement, and biofeedback. Research shows their utility in ADHD, autistic spectrum disorders, eating disorders, post-traumatic stress, impulse control disorders, depression, schizophrenia, dementia, and even healthy aging. Virtual reality and artificial intelligence have been used in conjunction with gaming interventions to improvise their scope. Even though these interventions hold promise in engagement, ease of use, reduction of stigma, and bridging the mental-health gap, there are pragmatic challenges, especially in developing countries. These include network quality, infrastructure, feasibility, socio-cultural adaptability, and potential for abuse. Keeping this in the background, this review summarizes the scope, promise, and evidence of digital gaming in psychiatric practice, and highlights the potential caveats in their implementation.

Frontal GABA in schizophrenia: A meta-analysis of 1H-MRS studies.

OBJECTIVES: The primary objective was to conduct a meta-analysis of studies comparing the GABA levels of schizophrenia patients (SZP) and healthy controls (HC) using proton magnetic resonance spectroscopy (1H-MRS) in the frontal cortex (FC) and its sub-regions. METHODS: We included studies published in English language that used 1H-MRS from MRI scanners having at-least 3 Tesla (3 T) magnetic field strength to measure GABA levels in SZP (n = 699) and HC (n = 718) in FC and its sub-regions. The outcome measures were the means and standard deviations of GABA levels and outcome measure was calculated using a random-effect model. RESULTS: In FC, medial prefrontal cortex (MPFC) and dorsolateral prefrontal cortex (DLPFC), there were no significant group differences. On excluding the outlier studies, the GABA levels were lower in patients with schizophrenia compared to healthy controls in FC (Hedges' g = -0.2; p = 0.02). In ACC, significant group difference was noted in GABA levels (Hedges' g = -0.25; p = 0.03) with patients values being lower that is more pronounced in the first episode schizophrenia patients (Hedges' g: -0.41; p = 0.003). CONCLUSIONS: The available 1H-MRS studies suggest hypo-GABA ergia specifically in ACC and hint towards possible hypo GABA-ergic state in the FC. However, limitations of the analysis should be considered while interpreting the results.

Digital gaming interventions: a novel paradigm in mental health? Perspectives from India.

The mental health gap has been a persistent concern globally, especially in low and middle-income countries (LMIC). In an attempt to mitigate resource limitations, the psychiatric practice has been undergoing a paradigm shift into digitalized mental health interventions. One such innovation involves digital gaming utilizing the principles of 'gamification' to incorporate both the playfulness component of online gaming as well as the domain-targeted design of gaming elements. Digital gaming-based interventions have been to deliver psychotherapy, biofeedback, cognitive training and rehabilitation, as well as behavioural modification and social skills training. Research shows their utility in autism spectrum disorders, attention deficit disorders, schizophrenia, depression, anxiety disorders, post-traumatic stress, eating disorders, neurocognitive disorders and also to promote healthy aging. Though promising in scope, these interventions face pragmatic challenges for implementation in developing countries. Even though increased use of technology, internet penetration and growing digital literacy have enhanced their accessibility and feasibility, various factors like socio-cultural diversity, lack of standardization, poor infrastructural support, bandwidth issues and lack of practice can impair their use and acceptability. Keeping this in the background, this commentary critically discusses the scope, applications and challenges of digital gaming in mental healthcare delivery in one of the rapidly globalizing LMIC nations, India.

"Guarding the Gatekeepers": Suicides among Mental Health Professionals and Scope of Prevention, A Review.

Suicide is a social evil that is considered to be a global epidemic. Mental healthcare professionals (MHP) (psychiatrists, clinical psychologists, psychiatric social work, etc.) are often involved as 'gatekeepers' in the management of suicidality and suicide prevention. Even though the risk of suicide in medical profession has received attention in research, there has been scarcity of literature related to the same in MHPs. They are not immune to the perils of psychological distress and its cascading consequences including suicide, contrary to the popular societal myths. The intrinsic and extrinsic pressures of the profession, persistent discourse in managing the psychological distress of others, professional burnout, self-stigma, societal apathy and easy access to psychotropics are certain factors making the MHPs more vulnerable. This disengagement and stress can contribute to depression, anxiety and complex trauma in the MHPs. The situation is furthermore compounded in developing countries with resource constraints, low MHP: patient ratio and inflexibility of work schedules. This makes tailored interventions, peer counselling, periodic mental health screenings and administrative understanding and accountability necessary at all levels. Keeping this in background, the review glances at the risk factors of suicide related to MHPs, highlights the problem statement and discusses the possible interventions.

Perceptions, Experiences, and Challenges of Physicians Involved in Dementia Care During the COVID-19 Lockdown in India: A Qualitative Study.

Introduction: With 5.3 million people living with dementia in India and the pandemic wreaking havoc, dementia care has faced unique challenges during the outbreak, with reduced healthcare access, travel restriction, long-term lockdown and fear of hospitalization. We explored the experiences and barriers faced by the physicians involved in dementia care during the lockdown period. Methods: A qualitative approach was used with purposive sampling. After an initial pilot, 148 physicians were included in the study. They were virtually interviewed in-depth based on a pre-designed semi-structured questionnaire, in areas related to tele-consultations, attributes related to dementia care, challenges faced and way forward. Interviews were recorded, transcribed and thematically analyzed using Nvivo-10 software. Triangulation, peer debriefing and respondent validation were used to ensure rigor. Results: The overarching categories that emerged were "Tele-medicine as the future of dementia care in India," "people living with dementia being uniquely susceptible to the pandemic with a triple burden of: age, ageism and lack of autonomy" and "markedly reduced healthcare access in this population with significant mental health burden of caregivers." The experiences of the physicians were categorized into their challenges during the lockdown period and perceptions related to specific facets of dementia care during the crisis. The general physicians expressed special "unmet needs" of dementia-specific training and specialist collaboration. Most of the participants perceived ambiguity related to the newly released telepsychiatry guidelines. Conclusion: Resource constraints and pandemic burden are currently high. This study looks at the "voices" of those actively providing dementia care during the ongoing crisis and to the best of our knowledge, is the first one from India to do so. Concurring with their experiences, PwD and their families are exposed to multiple vulnerabilities during COVID-19, need tailored care, especially at the primary healthcare level which includes general physicians. These relevant "voices" are discussed in light of the new tele-psychiatry guidelines and further optimization of dementia care in an aging India.