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.

Current status of yoga in mental health services.

Yoga (derived from 'yuj' which means to yoke together or unite) has been used for millennia as a tool for self-improvement, with the ultimate goal of uniting the individual consciousness with the universal. The physical elements of yoga, although seen as necessary in the path to achieve the goal, they were not considered as the endpoint for a practitioner. Sage Patanjali, who codified the practices into an eight-limbed model (Ashtanga yoga) in the Patanjali Yoga Sutras, makes it clear that the target of yoga is primarily the mind. However, in the modern world, yoga practices have become immensely popular as aids to improve health. Yoga-based practices are being extensively used as therapeutic ingredients, alone or as adjuncts to other therapies in a variety of disorders, both physical and mental. There is now strong evidence to suggest that yoga-based interventions are beneficial in several lifestyle disorders. Recent research has also shown significant benefits in mental disorders such as depression, anxiety, and psychosis. This paper discusses the place of yoga as one of the therapeutic strategies in the holistic approach to mental disorders, and the challenges inherent to research in this area.

Yoga-based intervention in patients with somatoform disorders: an open label trial.

Somatoform disorders are common mental disorders associated with impaired functioning and increased utilization of health resources. Yoga-based interventions have been used successfully for anxiety, depression, and chronic pain conditions. However, literature on the use of yoga in treatment of somatoform disorders is minimal. The current study assessed the effect of a specific yoga-based intervention in patients with somatoform disorders. Consenting patients meeting ICD-10 criteria for somatoform disorders were offered a specific yoga module (1 h per day) as a treatment. Assessments including Visual Analogue Scale (VAS), Brief Pain Inventory (BPI), and others were carried out at baseline and after 2, 6, and 12 weeks. Sixty-four subjects were included in the study and 34 completed 12 weeks follow-up. Significant improvement was noted in pain severity from baseline to 12 weeks after regular yoga sessions. The mean VAS score dropped from 7.24 to 2.88. Worst and average pain score in the last 24 h on BPI dropped from 7.71 to 3.26 and from 6.12 to 2.0,7 respectively. Results of the study suggest that yoga-based intervention can be one of the non-pharmacological treatment options in somatoform disorders. These preliminary findings need replication in larger controlled studies.

Yoga and physical exercise - a review and comparison.

Yoga is a multifaceted spiritual tool with enhanced health and well-being as one of its positive effects. The components of yoga which are very commonly applied for health benefits are asanas (physical postures), pranayama (regulated breathing) and meditation. In the context of asanas, yoga resembles more of a physical exercise, which may lead to the perception that yoga is another kind of physical exercise. This article aims at exploring the commonalities and differences between yoga and physical exercise in terms of concepts, possible mechanisms and effectiveness for health benefits. A narrative review is undertaken based on traditional and contemporary literature for yoga, along with scientific articles available on yoga and exercise including head-to-head comparative trials with healthy volunteers and patients with various disease conditions. Physical exercises and the physical components of yoga practices have several similarities, but also important differences. Evidence suggests that yoga interventions appear to be equal and/or superior to exercise in most outcome measures. Emphasis on breath regulation, mindfulness during practice, and importance given to maintenance of postures are some of the elements which differentiate yoga practices from physical exercises.

Designing and validation of a yoga-based intervention for obsessive compulsive disorder.

Some yoga-based practices have been found to be useful for patients with obsessive compulsive disorder (OCD). The authors could not find a validated yoga therapy module available for OCD. This study attempted to formulate a generic yoga-based intervention module for OCD. A yoga module was designed based on traditional and contemporary yoga literature. The module was sent to 10 yoga experts for content validation. The experts rated the usefulness of the practices on a scale of 1-5 (5 = extremely useful). The final version of the module was pilot-tested on patients with OCD (n = 17) for both feasibility and effect on symptoms. Eighty-eight per cent (22 out of 25) of the items in the initial module were retained, with modifications in the module as suggested by the experts along with patients' inputs and authors' experience. The module was found to be feasible and showed an improvement in symptoms of OCD on total Yale-Brown Obsessive-Compulsive Scale (YBOCS) score (p = 0.001). A generic yoga therapy module for OCD was validated by experts in the field and found feasible to practice in patients. A decrease in the symptom scores was also found following yoga practice of 2 weeks. Further clinical validation is warranted to confirm efficacy.

Serum cortisol and BDNF in patients with major depression-effect of yoga.

Depression is associated with low serum Brain Derived Neurotrophic Factor (BDNF) and elevated levels of serum cortisol. Yoga practices have been associated with antidepressant effects, increase in serum BDNF, and reduction in serum cortisol. This study examined the association between serum BDNF and cortisol levels in drug-naïve patients with depression treated with antidepressants, yoga therapy, and both. Fifty-four drug-naïve consenting adult outpatients with Major Depression (32 males) received antidepressants only (n = 16), yoga therapy only (n = 19), or yoga with antidepressants (n = 19). Serum BDNF andcortisol levels were obtained before and after 3 months using a sandwich ELISA method. One-way ANOVA, Chi-square test, and Pearson's correlation tests were used for analysis. The groups were comparable at baseline on most parameters. Significant improvement in depression scores and serum BDNF levels, and reduction in serum cortisol in the yoga groups, have been described in previous reports. A significant negative correlation was observed between change in BDNF (pre-post) and cortisol (pre-post) levels in the yoga-only group (r = -0.59, p = 0.008). In conclusion, yoga may facilitate neuroplasticity through stress reduction in depressed patients. Further studies are needed to confirm the findings and delineate the pathways for these effects.

Hyperprolactinemia with aripiprazole: understanding the paradox.

Aripiprazole, due to its partial agonist activity at the D2 receptors, is often recommended as the drug of choice in patients who develop antipsychotic-induced hyperprolactinemia. We report a case of a female patient who developed hyperprolactinemia while on treatment with aripiprazole. This partial D2 agonistic activity of aripiprazole could be dose related, and hence, at higher doses, aripiprazole by itself can have dopamine antagonistic properties and hence cause prolactin system abnormalities.

Clinical effects of a yoga-based intervention for patients with schizophrenia - A six-month randomized controlled trial.

BACKGROUND: Yoga has shown promise as an add-on therapy for patients with schizophrenia. However, most studies have been short-term, with methodological limitations. METHODS: We conducted a six-month parallel-group randomized-controlled trial (with rater blinding) to evaluate the effectiveness of a yoga-based intervention in improving symptoms and quality of life in patients with schizophrenia. We recruited 110 patients from an urban tertiary hospital and a semi-urban community centre who met DSM 5 criteria for schizophrenia and were on stable medication for at least six weeks. Participants were randomly assigned to either yoga add-on therapy (YT) or treatment-as-usual (TAU) groups. Clinical assessments were conducted at baseline and at one, three and six months. The primary outcome was changes in positive/negative symptom scores and secondary outcomes included changes in quality of life, perceived stress and socio-occupational functioning. RESULTS: Intention to treat analysis with a longitudinal mixed model approach revealed a significant group-by-time interaction with the YT group showing medium effect improvements in negative symptoms (η2p = 0.06) and small effect improvements in positive symptoms (η2p = 0.012), WHOQOL-BREF quality of life [psychological well-being (η2p = 0.015) and environmental health (η2p = 0.048)] when compared to TAU. The patients successfully learned and performed yoga practices without reporting any significant adverse effects. DISCUSSION: Our findings suggest that yoga-based intervention may be a valuable adjuvant therapy for medication-stabilized patients with schizophrenia, especially in ameliorating negative symptoms and enhancing quality of life. Future controlled trials, including active physical interventions, are crucial to validate yoga's efficacy, optimize clinical use, and elucidate underlying mechanisms.

Vitamin B12 levels and psychiatric symptomatology: a case series.

Cobalamin (Vitamin B12) has been implicated in the pathogenesis of various neuropsychiatric disorders. A review of 19 patients (14 vegetarians) with demonstrable vitamin B12 deficiency showed varied psychiatric symptomatology, with the majority not having significant hematological or neurological manifestations.

Evidence-based integration of yoga in psychiatric practice.

Yoga has been put to test in clinical medicine to build evidence. There has been a steep rise in yoga research through 2010, threefold in the next decade. Despite challenges, clinicians have explored yoga intervention in several disorders. The available data have been examined using meta-analysis when there are more studies. Psychiatric disorders treated with yoga have attracted more research. Some examples include depression, schizophrenia, anxiety, obsessive-compulsive disorder (OCD), somatoform pain, addiction, mild cognitive impairment, and elderly and childhood disorders. Current manuscript focuses on highlighting the major steps towards generating evidence that have led to integration of yoga into psychiatry practice. It also discusses various challenges and the way forward.

Composition of yoga-philosophy based mental traits (Gunas) in major psychiatric disorders: A trans-diagnostic approach.

Yoga philosophy includes the theory of Tri-guna (three mental traits): sattva (signifies a tendency to 'goodness'), rajas (tendency towards 'activity'), and tamas (tendency towards "inertia"). This cross-sectional study aimed to understand the differences in the expression of gunas in patients suffering from major psychiatric disorders (n = 113, 40 females) and age-gender-education-matched healthy controls (HCs; n = 113, 40 females). Patients were diagnosed by a psychiatrist using DSM 5 criteria and suffered from the following disorders: depression (n = 30), schizophrenia (SCZ; n = 28), obsessive-compulsive disorder (OCD; n = 23), anxiety (n = 16), and bipolar affective disorder (BPAD; n = 16). Tri-gunas were assessed using a validated tool (Vedic Personality Inventory) and symptoms were assessed using standard scales as per the diagnosis. Multi-variate analysis of variance (MANOVA) was used to assess the differences in guna scores between HCs and patients, and between patients with different diagnoses. A two-tailed Pearson correlation was performed between the gunas and psychometric scales. Results revealed that HCs had significantly higher sattva traits as compared to patients (except those with OCD). Each psychiatric diagnosis also showed a specific guna configuration: (1) Anxiety disorders and OCD: High sattva-rajas, low tamas; (2) Depression: High sattva-tamas, low rajas; (3) Psychotic disorders (SCZ/BPAD): High tamo-rajas, low sattva. Significant positive correlations were observed between rajas traits and anxiety/OC/positive psychotic symptoms, negative psychotic symptoms and tamas traits, and sattva traits and OC symptoms. This finding has clinical implications, both to develop ways of predicting outcomes of psychiatric disorders, as well as to develop psycho-therapeutic and lifestyle interventions targeting the gunas.

Yoga and Integrative Healthcare: Lessons from the National Institute of Mental Health and Neurosciences (NIMHANS) in India.

Background: There is growing evidence and increasing interest for systemic integration of medicine (synergistic and evidence-based combination of different systems along with conventional biomedicine). The National Institute of Mental Health and Neurosciences (NIMHANS), an Institute of National Importance and a tertiary mental and neurological healthcare hospital situated in Bengaluru, India, has established one such integrative model. The present manuscript traces the history and describes the important steps followed in this integrative approach. Methodology: The NIMHANS model followed a stage-wise two-step approach: (1) First stage - Starting with Integration of Yoga: The process began more than a decade ago, with integrating yoga into a clinical department (rather than an exclusive research-based approach) of the institute which had relatively high clinical service load (For example, Department of Psychiatry in NIMHANS). Yoga was gradually formalized into academic and clinical activities (outpatient and inpatient services) by appointing a Yoga faculty with a medical background with an MD/PhD in Yoga. The research was primarily directed by the clinical observations of patients receiving yoga therapy. (2) Second stage: Adding an appropriate and compatible discipline from Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) system (Ayurveda in this case): The center for yoga gradually evolved into the Department of Integrative Medicine with the appointment of faculty from the Ayurveda stream. In this model, specialists from each discipline provide clinical inputs after simultaneous consultation with the patient through systemic integration in clinical, academic, and research domains rather than mere co-location of AYUSH services with mainstream medicine. Conclusion: The NIMHANS model of integration suggests the application of yoga into mainstream clinical service as the first step toward integration. Yoga should be added as a formalized clinical discipline with systemic integration. Gradually, other feasible systems of traditional medicine from AYUSH can be integrated at a later stage in a step-by-step manner based on clinical practice and evidence.

Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia.

OBJECTIVE: Facial emotion recognition deficits have been consistently demonstrated in schizophrenia and can impair socio-occupational functioning in these patients. Treatments to improve these deficits in antipsychotic-stabilized patients have not been well studied. Yoga therapy has been described to improve functioning in various domains in schizophrenia; however, its effect on FERD is not known. METHOD: Antipsychotic-stabilized patients randomized to receive Yoga (n=27), Exercise (n=17) or Waitlist group (n=22) were assessed at baseline, 2nd month, and 4th month of follow-up by raters blind to group status. Assessments included Positive and Negative Syndrome Scale (PANSS), Socio-Occupational Functioning Scale (SOFS), and Tool for Recognition of Emotions in Neuropsychiatric DisorderS (TRENDS). RESULTS: There was a significant positive correlation between baseline FERD and socio-occupational functioning (r=0.3, P=0.01). Paired samples t test showed significant improvement in positive and negative symptoms, socio-occupational functioning and performance on TRENDS (P<0.05) in the Yoga group, but not in the other two groups. Maximum improvement occurred at the end of 2 months, and improvement in positive and negative symptoms persisted at the end of 4 months. CONCLUSION: Yoga therapy can be a useful add-on treatment to improve psychopathology, FERD, and socio-occupational functioning in antipsychotic-stabilized patients with schizophrenia.

Generic Yoga Modules for Clinical and Research Settings-Need of the Hour.

Yoga-based interventions offer significant promise in healthcare. However, meta-analyses of various yoga trials suggest that comparisons of trials are either not possible or difficult due to heterogeneity in therapeutic yoga interventions. Also, in view of emerging evidence for the role of therapeutic yoga, it is important to identify the specificity and validity of various yoga components being used in different trials. Efforts in this direction will be fruitful only if a systematic approach is adopted to develop yoga programs for various ailments. In this article, we emphasize the need for a "generic yoga" concept for designing a therapeutic yoga program for particular health issues, with the objectives of promoting scientific growth of therapeutic applications of yoga and widespread application of standardized therapeutic yoga programs within a biomedical framework. This generic therapeutic yoga will essentially highlight the development-validation process of uncopyrighted yoga programs; their components, benefits, and possible side-effects; and requirement for need-based modifications.

Yoga therapy for social cognition in schizophrenia: An experimental medicine-based randomized controlled trial.

Negative symptoms and cognitive deficits are difficult-to-treat symptoms of schizophrenia. In this single blind randomized controlled study, we compared change in social cognitive performance in persons with Schizophrenia (PWS) (as per DSM-5), after 6 weeks of yoga intervention with a waitlist control group. We also examined changes in putative Mirror Neuron System (MNS) activity measured by Transcranial Magnetic Stimulation (TMS) in a subset of sample (n = 30). 51 PWS stabilized on antipsychotic medication for at least 6 weeks, were assigned to add-on yoga therapy (YT) (n = 26) or waitlist (WL) (n = 25). Subjects in the YT group received add-on yoga therapy (20 sessions in 6 weeks). Both the groups continued their standard treatment and were assessed at baseline and after 6 weeks for social cognition, clinical symptoms and social disability. RM-ANOVA showed significant interaction between time and group for social cognition composite score (SCCS) (F = 42.09 [1,44], P < 0.001); negative symptoms (SANS) (F = 74.91 [1,45], P < 0.001); positive symptoms (SAPS) (F = 16.05 [1,45], P < 0.001) and social disability (GSDS) (F = 29.91 [1,46], P < 0.001). MNS activity had increased after 6 weeks in both groups but not of statistical significance. This study demonstrates that 6 weeks of add-on yoga therapy could improve social cognition in PWS compared to waitlist control subjects. However, the change in social cognition was not associated with a change in the putative MNS-activity. It necessiatates further studies to investigate the mechanistic processes of yoga and replicate these observations in a larger sample.

Tele-Yoga Therapy for Common Mental Health Disorders: Need for Assessment Tool and Guidelines.

INTRODUCTION: Tele-yoga is a cost-effective method of teaching yoga using cloud technology to relay from one source (trainer's venue) to multi-point video conferencing centers (participants' homes). However, there is a need to assess the tele-yoga trainer and the training itself to ensure safety and effectiveness. MATERIALS AND METHODS: The Tele-Yoga Trainers Assessment (TYTA) tool was developed through (a) review of existing tools, (b) key informant interviews, and (c) validation by experts. It was tested for its feasibility in six persons with common mental disorders. A trained yoga therapist conducted tele-yoga therapy sessions which was webcast from NIMHANS Integrated Center for Yoga to NIMHANS Center for Well-Being for the first 15 days and to the respective homes of the participants using "Skype" in the remaining 15 days. Participants were assessed on (a) mental well-being, (b) satisfaction with overall health and were administered the (c) TYTA tool on the 1st, 15th, and 30th day. RESULTS: The TYTA was easy to administer for assessing the performance of the yoga trainer. The qualitative case reports of individual participants depicted that over 30 days, mental well-being and satisfaction with overall health improved trainer's performance. CONCLUSION: Tele-yoga therapy is feasible with minimum technology and availability of good internet access at the relay and reception site. The trainer must be assessed for his/her suitability and be provided guidelines for achieving desired outcomes.

Yoga Module for Somatoform Pain Disorders: Development, Content Validation, and Feasibility Testing.

BACKGROUND: Yoga practices have been found to be useful in chronic pain conditions but studies focussing specifically on somatoform pain disorders (SPDs) are limited. AIMS: Current study aims to develop and test the feasibility of a yoga program for patients with SPDs. MATERIALS AND METHODOLOGY: Athorough search of traditional and contemporary literature was performed with the objective of formulating a yoga program for reducing chronic non-specific pain and associated psychological distress. Content validity of the program was then determined by taking the opinion of 18 yoga experts (who had >5 years of experience in treating mental health disorders) using content validation ratio (CVR) through Lawshe's formula. The feasibility of the module was tested on 10 subjects diagnosed with SPDs as per the International Classification of Diseases (ICD) -10 criteria using standard scales. RESULTS: In the finalized module, 70.83% (34 out of 48 items) of the practices were retained along with the modifications as suggested by the experts. Two practices were not found to be feasible (Trikonasana and Shalabhasana) and hence were removed from the final module. A significant reduction in pain severity was observed in the subjects after practising the yoga module for 2 weeks. The content validity index for the whole module (average of all CVRs) was 0.55. CONCLUSIONS: Ayoga module was developed for SPD. The content validity of the module was found to be good. The module was found safe and potentially useful for reducing pain severity in patients with SPD. Future studies should test the efficacy of the developed program through a randomized controlled clinical trial.

Effects of a yoga breath intervention alone and in combination with an exposure therapy for post-traumatic stress disorder and depression in survivors of the 2004 South-East Asia tsunami.

OBJECTIVE: This study evaluated the effect of a yoga breath program alone and followed by a trauma reduction exposure technique on post-traumatic stress disorder and depression in survivors of the 2004 Asian tsunami. METHOD: In this non-randomized study, 183 tsunami survivors who scored 50 or above on the Post-traumatic Checklist-17 (PCL-17) were assigned by camps to one of three groups: yoga breath intervention, yoga breath intervention followed by 3-8 h of trauma reduction exposure technique or 6-week wait list. Measures for post-traumatic stress disorder (PCL-17) and depression (BDI-21) were performed at baseline and at 6, 12 and 24 weeks. Data were analyzed using anova and mixed effects regression. RESULTS: The effect of treatment vs. control was significant at 6 weeks (F(2,178) = 279.616, P < 0.001): mean PCL-17 declined by 42.5 +/- 10.0 SD with yoga breath, 39.2 +/- 17.2 with Yoga breath + exposure and 4.6 +/- 13.2 in the control. CONCLUSION: Yoga breath-based interventions may help relieve psychological distress following mass disasters.

A survey of the practice of electroconvulsive therapy in Asia.

OBJECTIVE: To describe a comprehensive survey of the practice of electroconvulsive therapy (ECT) in Asia. METHOD: Between 2001 and 2003, a 29-item questionnaire was sent to 977 psychiatric facilities in 45 Asian countries. RESULTS: Completed questionnaires were returned by 334 (34.2%) institutions in 29 (64.4%) countries. Electroconvulsive therapy was available in 257 institutions in 23 countries. During the year before the survey, 39,875 patients (62% men) received a mean of 7.1 ECT treatments. Most patients (73.1%) were 18 to 44 years old; few were younger than 18 years (6.0%) or older than 64 years (4.4%). Indications for ECT were schizophrenia (41.8%), major depression (32.4%), mania (14.0%), catatonia (6.9%), drug abuse (1.8%), dysthymia (1.6%), and others. Brief-pulse ECT devices were used in only 115 (58.4%) of 197 institutions. Routine electroencephalographic monitoring was conducted in only 59 (23.0%) institutions. Bilateral electrode placement was invariable in 202 (78.6%) institutions. Unmodified ECT was administered to 22,194 (55.7%) patients at 141 (54.9%) institutions in 14 countries. Continuation ECT was available in only 115 (44.7%) institutions in 17 countries. No institution had a formal ECT training program. CONCLUSIONS: The practice of ECT in Asia may seem suboptimal: schizophrenia, not depression, is the most common indication; most institutions offer sine-wave ECT; unmodified ECT is commonly administered; bilateral electrode placement is invariable in most institutions; electroencephalographic monitoring is uncommon; continuation ECT is infrequent; and no formal training in ECT is available. We speculate that the suboptimal practices reflect felt needs and ground realities in standards of medical care in developing countries rather than a misuse of ECT.