Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study, a collaborative study carried out in 14 countries.

AIMS: To assess the prevalence and management of depressive disorders in people with Type 2 diabetes in different countries. METHODS: People with diabetes aged 18-65 years and treated in outpatient settings were recruited in 14 countries and underwent a psychiatric interview. Participants completed the Patient Health Questionnaire and the Problem Areas in Diabetes scale. Demographic and medical record data were collected. RESULTS: A total of 2783 people with Type 2 diabetes (45.3% men, mean duration of diabetes 8.8 years) participated. Overall, 10.6% were diagnosed with current major depressive disorder and 17.0% reported moderate to severe levels of depressive symptomatology (Patient Health Questionnaire scores >9). Multivariable analyses showed that, after controlling for country, current major depressive disorder was significantly associated with gender (women) (P<0.0001), a lower level of education (P<0.05), doing less exercise (P<0.01), higher levels of diabetes distress (P<0.0001) and a previous diagnosis of major depressive disorder (P<0.0001). The proportion of those with either current major depressive disorder or moderate to severe levels of depressive symptomatology who had a diagnosis or any treatment for their depression recorded in their medical records was extremely low and non-existent in many countries (0-29.6%). CONCLUSIONS: Our international study, the largest of this type ever undertaken, shows that people with diabetes frequently have depressive disorders and also significant levels of depressive symptoms. Our findings indicate that the identification and appropriate care for psychological and psychiatric problems is not the norm and suggest a lack of the comprehensive approach to diabetes management that is needed to improve clinical outcomes.

The INTERPRET-DD study of diabetes and depression: a protocol.

AIM: People with diabetes are at an increased risk of developing depression and other psychological disorders. However, little is known about the prevalence, correlates or care pathways in countries other than the UK and the USA. A new study, the International Prevalence and Treatment of Diabetes and Depression Study (INTERPRET-DD) aims to address this dearth of knowledge and identify optimal pathways to care across the globe. METHOD: INTERPRET-DD is a 2-year longitudinal study, taking place in 16 countries' diabetes outpatients' facilities, investigating the recognition and management of depressive disorders in people with Type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognized (undocumented) depression on clinical outcomes and emotional well-being are being investigated. RESULTS: Initial evidence indicates that a range of pathways to care exist, with few of them based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both the symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use. CONCLUSIONS: Our study will increase the understanding of the impact of comorbid diabetes and depression and identify the most appropriate (country-specific) pathways via which patients receive their care. It addresses an important public health problem and leads to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with comorbid diabetes and depression.

Effectiveness of multi-disciplinary structured training program on mentoring and mental well-being for officers and instructors in the Indian Air Force.

Background: The military environment is characterized by unpredictable situations, intensive training, demanding workload, and job-associated stressors, which make it highly stressful. Mentorship and mental well-being training could be beneficial to both officers and the new adolescent recruits of the Indian Air Force (IAF). Aim: This study aimed at evaluating the effect of a multi-disciplinary structured training on mentoring and mental well-being among officers and instructors in the IAF. Methods: Seventy IAF officers/instructors underwent a week-long multi-disciplinary structured training program, which was conducted at a tertiary care neuro-psychiatric hospital in South India. A quasi-experimental design with a single-group pre- and post-test was adopted. Outcome measures included a) knowledge on mentorship and mental health and b) self-perceived competence in addressing mental health distress. Results: Post training, there was a statistically significant improvement in scores on mentorship/mental health knowledge and a significant increase in self-perceived competence in addressing mental distress. Conclusion: Mentorship and mental well-being training for officers and instructors in the IAF improved mental health knowledge and self-perceived competence. Therefore, administration of regular and in-depth structured mental health-related training interventions could be beneficial not only to the officers but also to the new recruits/mentees in the IAF.

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.

Effect of photoperiod and temperature on testicular regression in Channa punctatus.

In Channa punctatus testicular regression commonly observed during spawning and postspawing phases of reproductive cycle. In the present study testicular regression was frequently noticed in fish maintained under both long photoperiod-warm temperature (LD 16 : 8-30 degrees C) and short photoperiod-warm temperature (LD 8 : 16-30 degrees C) regimes. Testicular regression was characterized by distortion of cellular boundary of lobules and formation of collagenous capsules containing degenerating germ cells, blood cells and colloidal mass within the lobules. The magnitude of testicular regression was more in fish exposed to short photoperiod regime (R-73.33%, SP-41.67%) than long photoperiod regime (R-50.83%, SP-19.16%) and control group (R-20.83%, SP-16.67%) in both resting (R) and spawning (SP) phases. Further the frequency of testicular regression during resting phase was 73.33% (short photoperiod), 50.83% (long photoperiod) and 20.83% (control) whereas during spawning phase was 41.67% (short photoperiod) 19.16% (long photoperiod) and 16.67% (control). In the present study occurrence of more testicular regression during resting phase than spawning phase may be due to change in the endogenous condition of the fish.

Effective use of social media platforms for promotion of mental health awareness.

BACKGROUND: Social media platforms are progressively developing as a rich source of mass communication. Increasing mental health awareness with the help of social media can be a good initiative to reach out to a large number of people in a short time frame. This study was conducted to understand the usefulness of social media platforms for health promotion. MATERIALS AND METHODS: It was a qualitative study to evaluate the effectiveness of social media platforms in hosting health promotion campaigns in the field of mental health, which was observed over 5 months from May to September 2019 to reach more people for effective information dissemination. The campaigns were as follows (1) The Buddies for Suicide Prevention: an online campaign to create awareness about suicide prevention. The campaign included script writing, slogan writing, poster making, and short films making, organized for the general public who were interested to take part; (2) The #Iquitobacco was a 21-day campaign with an idea of tobacco cessation in the community, conducted among social media viewers who were willing to participate; and (3) #Migrainethepainfultruth was yet another campaign conducted among the social media viewers who were interested to participate. All the campaigns were conducted using two famous social media platforms commonly used by young adults. Descriptive statistics such as frequency and proportions were computed for the number of likes and shares. RESULTS: The Facebook and Instagram posts concerning all the campaigns brought about a considerable amount of reach to the targeted population. After the campaigns, the page reached to around 10.3 k people (both fans and nonfans). CONCLUSIONS: Use of social media to conduct mental health campaigns is an effective initiative as one can reach out to several people over a short time period. There is an increasing trend in the awareness of mental health with the effective use of digital media as a platform for disseminating information.

Supported employment programme for persons with severe mental disorders in India: A feasibility study.

BACKGROUND: A number of persons with severe mental illnesses are unable to prepare for, find or keep a job due to factors linked to their illness as well as psychosocial issues. AIM: To test the feasibility of a supported employment programme to help persons with severe mental disorders obtain and sustain employment. METHODS: A supported employment programme was developed for persons with severe mental disorders with components of (a) assessment of vocational potential, (b) vocational counselling, (c) networking and liaison with prospective employers, (d) job-related training and placement and (e) continued support for 6 months. Job placement status, social occupational functioning and disability (quantitative data) and benefits of enrolling in the employment programme (qualitative data) were assessed. RESULTS: A total of 40 employers were liaised with for providing job placement and reasonable accommodation. Out of 63 participants recruited into the study, 32 (50.8%) participants were placed in competitive jobs, placement was actively attempted for 17 (27.0%) participants, 7 (11.1%) were referred for skill training and 7 (11.1%) dropped out from the study. The disability score significantly reduced and socio-occupational functioning significantly improved in those who were placed over a period of 6 months. CONCLUSION: The supported employment programme was found to be feasible as it showed good placement rates and improvement in socio-occupational functioning and disability scores.

Factors associated with the onset of major depressive disorder in adults with type 2 diabetes living in 12 different countries: results from the INTERPRET-DD prospective study.

AIMS: To examine the factors that are associated with changes in depression in people with type 2 diabetes living in 12 different countries. METHODS: People with type 2 diabetes treated in out-patient settings aged 18-65 years underwent a psychiatric assessment to diagnose major depressive disorder (MDD) at baseline and follow-up. At both time points, participants completed the Patient Health Questionnaire (PHQ-9), the WHO five-item Well-being scale (WHO-5) and the Problem Areas in Diabetes (PAID) scale which measures diabetes-related distress. A composite stress score (CSS) (the occurrence of stressful life events and their reported degree of 'upset') between baseline and follow-up was calculated. Demographic data and medical record information were collected. Separate regression analyses were conducted with MDD and PHQ-9 scores as the dependent variables. RESULTS: In total, there were 7.4% (120) incident cases of MDD with 81.5% (1317) continuing to remain free of a diagnosis of MDD. Univariate analyses demonstrated that those with MDD were more likely to be female, less likely to be physically active, more likely to have diabetes complications at baseline and have higher CSS. Mean scores for the WHO-5, PAID and PHQ-9 were poorer in those with incident MDD compared with those who had never had a diagnosis of MDD. Regression analyses demonstrated that higher PHQ-9, lower WHO-5 scores and greater CSS were significant predictors of incident MDD. Significant predictors of PHQ-9 were baseline PHQ-9 score, WHO-5, PAID and CSS. CONCLUSION: This study demonstrates the importance of psychosocial factors in addition to physiological variables in the development of depressive symptoms and incident MDD in people with type 2 diabetes. Stressful life events, depressive symptoms and diabetes-related distress all play a significant role which has implications for practice. A more holistic approach to care, which recognises the interplay of these psychosocial factors, may help to mitigate their impact on diabetes self-management as well as MDD, thus early screening and treatment for symptoms is recommended.

Ethical dilemmas in palliative care in traditional developing societies, with special reference to the Indian setting.

BACKGROUND: There are intriguing and challenging ethical dilemmas in the practice of palliative care in a traditional developing society. OBJECTIVE: To review the different ethical issues involved in cancer and palliative care in developing countries, with special reference to India. METHODS: Published literature on pain relief and palliative care in the developing countries was reviewed to identify ethical issues and dilemmas related to these, and ways in which ethical principles could be observed in delivery of palliative care in such countries are discussed. RESULTS: The literature review revealed a number of ethical dilemmas and challenges that professionals, cancer patients and their families encountered during palliative care. It was noted that patients' preferences and decisions are influenced by family members. Dilemmas leave the professionals and families confused about how ethical their actions have been. Specific ethical issues were noted in relation to the availability and use of oral morphine for pain relief, spiritual care, lack of adequate palliative care services, and palliative care education. CONCLUSIONS: The four principles of ethics posed difficulties in understanding the complex ethical issues in a developing country with a traditional background. Ethical issues need to be handled delicately and sensitively in palliative care settings, within the framework of the traditions and culture of the society and financial constraints. The possible role of ethics committees in palliative care settings to help decision-making needs to be studied and discussed.

Osmotic adjustment increases water uptake, remobilization of assimilates and maintains photosynthesis in chickpea under drought.

Eight chickpea advanced breeding lines (ABLs) and their parents were evaluated for osmotic adjustment (OA), leaf carbohydrates and gas exchange under dryland field . These (ABLs) were derived from crosses between CTS 60543 x Kaniva and Tyson x Kaniva. Mean leaf water potential (LWP) fell down from -1.00 MPa at pre-stress level to about -2.25 MPa during terminal stress. Relative water content (RWC) showed periodic changes with alternate decrease or increase at certain interval, which also influenced the values of OA (low or high) in number of genotypes e.g. Kaniva, CTS 60543, Tyson and M 75. Significant variation in OA ranging 0.45 to 0.88 MPa was observed at high level of stress at -2.5 MPa. However, none of the genotypes showed stability of OA over the period of stress. Leaf starch declined even at mild stress (LWP, -1.6 MPa) resulting in an increase in hexose sugars and activation state of sucrose-phosphate synthase (SPS) that led to accumulation of sucrose. Both photosynthesis (Pmax) and transpiration decreased concurrently in two chickpea lines M 129 and Tyson with increasing water stress. However, rate of decline in the photosynthesis slowed down even drought was further intensified. The observed periodic changes in OA, RWC and photosynthesis appeared to be associated with drought-induced changes in SPS and carbohydrates which modify water uptake of the leaves.

Non-organic somatic symptoms in cancer.

Somatic symptoms considered as unrelated to cancer or grossly out of proportion to the known pathology were systematically assessed in a group of 98 consecutively referred cases. Subjects with prominent somatic symptoms (somatisers) had depression (53%), anxiety (12%) and atypical somatoform disorder (27%). During follow-up, somatisers with depression showed clinical improvement whereas those with atypical somatoform disorder showed no improvement or deteriorated. Methods of distinguishing the cause of somatic symptoms in cancer patients are discussed.

Metoprolol in the treatment of neuroleptic-induced tremor: case report.

A case report is presented documenting definite beneficial effect of metoprolol, a beta-selective adrenoceptor antagonist, in alleviating neuroleptic-induced coarse tremors. The tremors could not be controlled with antiparkinsonian agents. Metoprolol may prove to be an effective alternative in managing such side effects as tremors. The possible mechanisms of action are discussed.

Recurrence of hallucinations in consecutive episodes of schizophrenia and affective disorder.

48 patients with episodic psychosis (18 schizophrenia, 30 MDP) were studied to examine whether they had similar hallucinations in consecutive episodes. 34 cases reported hallucinations, 23 of whom had hallucinations in consecutive episodes. In 22 of these 23 cases, the same type of hallucination (in the same sense organ modality) recurred. A recurrence of similar content was found in nearly half of the cases. In cases in whom the hallucinatory content persisted, however, there was no persistence of delusional content. Similar neurophysiological disturbances in similar neuroanatomical regions may result in the persistence of the same hallucinations.

Consistency of delusions in schizophrenia and affective disorder.

The content of delusions were studied in a group of schizophrenics and affective disorder patients who had an episodic course to ascertain if the content of delusions remained similar or became dissimilar during different episodes. There were 18 schizophrenics and 30 affective disorder cases in this study. Consistency of delusional content was noted in one third of the cases in each group. Delusional content was consistent over episodes more often in Hindus (P less than 0.04), those married (P less than 0.03), and those from a rural background in the schizophrenic group. These differences were not observed in the affective disorder cases. Possible reasons for the consistence or non-consistence of delusional content are discussed.

Suicidal ideas during premenstrual phase.

The aim of the present study was to determine the frequency of suicidal ideas and death wish among 296 women from urban, rural, industrial and college populations. Suicidal ideas and/or death wish during premenstrual period were reported by 30 (10%) subjects, more so among college students and industrial working women and less among housewives. Premenstrual symptoms, like depression, irritability, mood swings, sense of losing control and water retention, were significantly more often reported by women who had suicidal ideas as compared with women without suicidal ideas.

A comparison of depressed and anxious chronic pain patients.

This study compared 102 depressed pain patients and 41 anxious pain patients. Depressed pain patients were significantly more often older in age. Pain patients with anxiety disorder were more often younger and unemployed. There was no significant difference in the family psychiatric morbidity. Such a subdivision of chronic pain patients based on psychopathology could be useful for management purposes and for future research.