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.

Models of Care of Schizophrenia in the Community-An International Perspective.

PURPOSE OF REVIEW: We reviewed the existing and recent community models of care in schizophrenia. We examine characteristics, recent updates, evidence, cost-effectiveness, and patients' acceptance for existing and new community-based care models in high-income (HI) and low- and middle-income (LAMI) countries. RECENT FINDINGS: Assertive Community Treatment (ACT), Intensive Case Management (ICM), and Crisis Intervention are cost-effective interventions for schizophrenia and time tested in the last few decades in HI countries. The growing evidence suggests that tailor-made ACTs and ICM can effectively reduce substance use, homelessness, and criminal activity in persons with schizophrenia who live in the community. Similarly, in LAMI Countries, a few community-based care models for schizophrenia have been developed and tested based on community-based rehabilitation principles. The modality of a community model of care and interventions for a person with schizophrenia should be chosen based on the person's co-existing psychosocial difficulties and challenges such as homelessness, criminal behaviour, and substance use.

Prevention of alcohol dependence: strategies for selective, indicated, and universal prevention.

Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us to design strategies for the prevention for ADS, which takes into account primary prevention (indicated, selective, and universal prevention) approaches and aims at reducing the occurrence of ADS. The objective of this work is to study the age-wise and order-wise chronologies of International Classification of Diseases Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR) dependence criteria in individuals with ADS. Consecutively admitted and consenting inpatients with ICD-10 DCR diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II. The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion, and ICD-10 dependence was 18.72 years (SD: 6.84), 24.33 years (SD: 9.21), and 27.51 years (SD: 9.28), respectively. In age-wise chronology, tolerance, loss of control, and craving were present in 97.53%, 80.24%, and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%), or loss of control (18.5%) was observed as the first criterion in 55.5% of the subjects. Indicated prevention may be attempted by enquiring about craving, tolerance, and loss of control and use of anticraving medications or behavioral strategies. Selective prevention by using naltrexone for those genetically inclined and universal prevention by use of "clinical" labeling on alcoholic beverages can also be attempted.

A Survey among Teachers of Psychiatry to Improve the Quality of Undergraduate Training: Outcomes from Karnataka.

BACKGROUND: In India, there is a large gap between the mental health morbidity in society and the availability of psychiatrists. However, the latest Indian undergraduate medical curriculum does not require any competency in psychiatry to be fulfilled for certification of medical graduates as doctors. Thus, the role of Indian psychiatry teachers is quite challenging. Interestingly, there has been hardly any effort to understand the felt needs of psychiatry teachers that may further improve the quality of undergraduate training. METHODS: We used a survey questionnaire that was both qualitative and quantitative, with questions on topics such as years of psychiatry training and experience as a psychiatry teacher. Do they feel the need for training in undergraduate psychiatry teaching? Do they require training in teaching psychiatry theory or clinics or both? What are the specific areas where they want training? What more should be planned for psychiatry teachers? Based on an online survey further steps in the direction of psychiatry teachers felt needs were initiated. RESULTS: Around 55 responses with a response rate of 37% were received. More than 50% were working in medical colleges for the last 5 years. About 80% felt the need for further training to teach medical students while 97% felt that additional training is required for handling theory as well as bedside clinic. More than 60% were keen to attend a 1-day workshop to upgrade their teaching skills. A majority wanted to have a forum to share their experiences and to learn from others. Based on the felt needs of psychiatry teachers from the survey, a 1-day workshop was carried out and a forum for psychiatry teachers was inaugurated. CONCLUSION: Training of psychiatry teachers is an important felt need for the challenges that are unique to Indian medical education. The outcome from the Karnataka survey is a progressive step in addressing this challenge.

Knowledge, attitude and practices of Indian dental surgeons towards tobacco control: advances towards prevention.

AIMS AND METHODS: We assessed the knowledge, attitude and practices of dental surgeons in the city of Bangalore, Karnataka, concerning use of tobacco in their patients. A self-administered questionnaire was administered to all dental surgeons prior to a sensitization program on nicotine dependence. RESULTS: The dental surgeons who responded (n=100) reported a need for increasing sensitization on the issue of tobacco especially among health professionals. Only 33% knew that nicotine is the most addictive drug and knowledge was poor about pharmacological as well as non pharmacological methods of treatment of nicotine dependence. Only 52% asked all their patients about tobacco use. However, almost all dental surgeons agreed that there should be a ban on public use of tobacco. IMPLICATIONS: The results of this study call for sensitizing health professionals on a larger scale on the issue of tobacco use and its treatment.

Expanding the schizophrenia phenotype: a composite evaluation of neurodevelopmental markers.

Minor physical anomalies (MPAs) and neurologic soft signs (NSSs) have been consistently reported to be more frequent in schizophrenia subjects and their first-degree relatives. We aimed at coassessing both these neurodevelopmental markers in neuroleptic-naive recent-onset schizophrenia (NRS) subjects in comparison to healthy control (HC) subjects to explore the predictive validity of this composite endophenotype. We administered the Modified Waldrop Scale (MWS) and the Neurological Evaluation Scale (NES) to evaluate MPAs and NSSs, respectively, in 40 NRS and 30 matched HC subjects. Schizophrenia subjects had significantly higher frequencies of MPAs and NSSs than HC. Minor physical anomaly total scores were correlated with greater severity of illness, whereas NES scores did not show any relationship with clinical variables. Schizophrenia and HC subjects were most accurately classified (82.9%) when MPAs and NSSs were considered as a composite phenotype rather than independently. Minor physical anomalies and NSSs constitute independent neurodevelopmental markers of schizophrenia and would afford greater predictive validity when used as a composite endophenotype in genetic association studies.

Chronology of alcohol dependence: implications in prevention.

BACKGROUND: Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us design strategies for the prevention for ADS, which aims at reducing the occurrence of ADS. OBJECTIVE: To study the age-wise and order-wise chronologies of ICD-10 (DCR) dependence criteria in individuals with ADS. MATERIALS AND METHODS: Consecutively admitted and consenting inpatients with ICD-10 (DCR) diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II. RESULTS: The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion and International Statistical Classification of Diseases and Related Health Problems 10(th) Revision (ICD-10) dependence was 18.72 years (SD, 6.84), 24.33 years (SD, 9.21) and 27.51 years (SD, 9.28), respectively. In age-wise chronology, tolerance, loss of control and craving were present in 97.53%, 80.24% and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%) or loss of control (18.5%) was observed in the first criterion in 55.5% of the subjects. CONCLUSIONS: Knowledge of chronology, its frequencies and time duration between various milestones in the development of the dependence criteria may enable the selection of the target population at an early stage. The pattern of development of dependence may provide us with an opportunity for interventions to reduce the incidence of ADS, as a step toward primary prevention. Adequate training of the primary care personnel and early psychiatric referral may help in the reduction in the incidence of ADS.

Somatization, somatosensory amplification, attribution styles and illness behaviour: a review.

Somatic symptoms have been conceptualized in many different ways in literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. This review focuses on existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization. Evidence suggests that somatosensory amplification is neither sensitive nor specific to somatizing states, and that other factors like anxiety, depression, neuroticism, alexithymia may also have an influence. Attribution research supports the existence of multiple causal attributions, which are related to the numbers of somatic symptoms. While somatizing patients have more organic attributions, depressed patients have more psychological attributions. A global somatic attribution style is associated with the number of obscure somatic symptoms, while a psychological attribution style is associated with both--psychological and somatic-- symptoms of depression and anxiety. There are conflicting findings with respect to the role of normalizing attributions in reducing physician recognition of anxiety and depression. Specific symptom attributions appear to explain physician recognition of psychological distress, but global attribution styles do not appear to explain any further variance in physician recognition beyond that explained by specific causal attributions. Illness behaviour has been studied in two distinct ways in literature. Research focusing on attendance rates as a form of illness behaviour suggests that somatization is associated with high levels of health care utilization. There is also some evidence that health care utilization, amplification and attributions styles may be interrelated among somatizing patients. More structured ways to assess illness behaviour have found high levels of abnormal illness behaviour in this population. Overall, research appears to suggest a complex (and as yet unclear) relationship between somatic symptoms and underlying cognitions/illness behaviours. While it is clear that somatization is closely related to a number of perceptual and cognitive-behavioural factors, the precise nature of these relationships are yet to be elucidated.

Delusion of test-tube pregnancy in a sexually abused girl.

We report the case of a patient who presented with catatonic features and delusion of test-tube pregnancy in the background of previous sexual abuse. The reported case illustrates the importance of contemporary themes in the evolution of psychopathology.