Context and contact: a comparison of patient and family engagement with early intervention services for psychosis in India and Canada.

BACKGROUND: It is unknown whether patient disengagement from early intervention services for psychosis is as prevalent in low- and middle-income countries (LMICs) like India, as it is in high-income countries (HICs). Addressing this gap, we studied two first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized lower service disengagement among patients and higher engagement among families in Chennai, and that family engagement would mediate cross-site differences in patient disengagement. METHODS: Sites were compared on their 2-year patient disengagement and family engagement rates conducting time-to-event analyses and independent samples t tests on monthly contact data. Along with site and family involvement, Cox proportional hazards regression included known predictors of patient disengagement (e.g. gender). RESULTS: The study included data about 333 patients (165 in Montreal, 168 in Chennai) and their family members (156 in Montreal, 168 in Chennai). More Montreal patients (19%) disengaged before 24 months than Chennai patients (1%), χ2(1, N = 333) = 28.87, p < 0.001. Chennai families had more contact with clinicians throughout treatment (Cohen's d = -1.28). Family contact significantly predicted patient disengagement in Montreal (HR = 0.87, 95% CI 0.81-0.93). Unlike in Chennai, family contact declined over time in Montreal, with clinicians perceiving such contact as not necessary (Cohen's d = 1.73). CONCLUSIONS: This is the first investigation of early psychosis service engagement across a HIC and an LMIC. Patient and family engagement was strikingly higher in Chennai. Maintaining family contact may benefit patient engagement, irrespective of context. Findings also suggest that differential service utilization may underpin cross-cultural variations in psychosis outcomes.

An observational study of antipsychotic medication discontinuation in first-episode psychosis: clinical and functional outcomes.

PURPOSE: To study the impact of supervised antipsychotic medication discontinuation on clinical and functional outcomes in first-episode psychosis (FEP) in two different cultural environments. METHOD: FEP patients(N = 253), treated in two early intervention services (Montreal, Canada and Chennai, India) for 2 years, were assessed for medication use, positive and negative symptom remission and social-occupational functioning at regular intervals. RESULTS: Between months 4 and 24 of treatment, 107 patients discontinued medication ('Off'group) as compared to 146 who stayed on medication ('On'group). Medication discontinuation was higher in Chennai as compared to Montreal (n = 80, 49.07% vs n = 27, 16.87%; χ2 37.80, p < 0.001), with no difference in time to discontinuation [Means(SDs) = 10.64(6.82) and 10.04(5.43), respectively, p = 0.71). At month 24 (N = 235), there were no differences in the rate of positive symptom remission between the on and Off groups (81.5 vs 88.0%, respectively) at both sites. The rate of negative symptom remission was lower among patients in the On compared to the Off group (63.2 vs 87.9%, respectively, χ2 = 17.91, p < 0.001), but only in Montreal (55.4% vs 80.0%, respectively, χ2 = 4.12, p < 0.05). Social and Occupational Functioning Assessment Scale scores were equally high in both Off and On medication groups in Chennai [Means (SDs) = 79.43(12.95) and 73.59(17.63), respectively] but higher in the Off compared to the On group in Montreal Means (SDs) = 77.47(14.97) and 64.94(19.02), respectively; Time × site interaction F = 3.96(1,217), p < 0.05]. Medication status (On-Off) had no impact on the outcomes, independent of other variables known to influence outcomes. CONCLUSION: Certain cultural environments and patient characteristics may facilitate supervised discontinuation of antipsychotic medication following treatment of an FEP without negative consequences.

Serum lipids and suicidal risk among patients with schizophrenia spectrum disorders: Systematic review and meta-analysis.

OBJECTIVE: A systematic review of literature was conducted to determine the association between serum lipids and suicidality in people with schizophrenia spectrum disorders. METHODS: We undertook a systematic search of multiple databases for studies that ascertained an association between serum lipids and suicidality in adult patients with schizophrenia spectrum disorders (18-65 years) from database inception to 2 September 2020. Qualitative analysis was done using National Institute of Health (NIH) scales. The standard mean difference (SMD) and 95% confidence intervals (CI) were calculated for each study and standardized relative to the study. Adjusted p-value, Z-test, and heterogeneity were calculated, as well as testing for publication bias. RESULTS: Of 1262 records identified, 17 studies (n = 3113) were included in our systematic review, while 11 studies were included in the meta-analysis. The majority of studies (11) rated fair on qualitative analysis. Data from seven studies (n = 1597) revealed a medium effect size for an association between low total cholesterol and suicide attempts (SMD -0.560; 95% CI: 0.949-0.170; p = 0.005). People with history of suicide attempt had a mean cholesterol value 0.56 SD lower than the mean in those without suicide attempts. There were differences in how a suicide attempt was defined and there was high heterogeneity (I2 = 83.3%). No significant association was found between any of the serum lipid parameters and suicide ideation. Funnel-plot analysis suggested small study effects with publication bias. CONCLUSIONS: Suicide attempts in people with schizophrenia spectrum disorders are associated with low mean total cholesterol levels.

The COVID-19 pandemic and its impact on mental health services: the provider perspective.

BACKGROUND: The impact of coronavirus disease 2019 on mental health of populations is in focus recently but few studies focus on service adaptations to ensure care provision for the mentally ill. In India, where community-based mental healthcare is led by non-government organizations (NGOs), this is a crucial time to gather evidence on how these organizations adapted to the challenges. METHODS: We explored provider perspectives in an NGO providing mental health services to communities using in-depth interviews and a focus group discussion to understand the impact on services and adaptations during the COVID 19 pandemic. RESULTS: Three elements of service provision were highlighted: established relationships with communities, responsiveness to the patient needs, and resilience in ensuring continuity. Responding to the end-to-end care needs of the clients and continual adaptations were vital for ensuring continued services. Telemedicine enabled expansion of service and clientele as well as efficiency, but there were issues of casualization of therapy and poor privacy. CONCLUSIONS: The study provides an understanding of adaptations to ensure continuity of care to mentally ill during disruptions. Insights from strategies are crucial to help plan for resilient community-based mental health care services.

Comparison of clinical outcomes following 2 years of treatment of first-episode psychosis in urban early intervention services in Canada and India.

BACKGROUND: Purported superior outcomes for treatment of psychosis in low- and middle-income (LMICs) compared with high-income (HICs) countries have not been examined in the context of early intervention services (EIS). AIMS: To compare 2-year clinical outcomes in first-episode psychosis (FEP) treated in EIS in Chennai (LMIC) and Montreal (HIC) using a similar EIS treatment protocol and to identify factors associated with any outcome differences. METHOD: Patients with FEP treated in EIS in Chennai (n = 168) and Montreal (n = 165) were compared on change in level of symptoms and rate and duration of positive and negative symptom remission over a 2-year period. Repeated-measures analysis of variance, and logistic and linear regression analyses were conducted. RESULTS: Four patients died in Chennai compared with none in Montreal. Family support was higher for Chennai patients (F = 14.05, d.f. = 1, P < 0.001, ƞp2 = 0.061) and increased over time at both sites (F = 7.0, d.f. = 1.915, P < 0.001, ƞp2 = 0.03). Negative symptom outcomes were significantly better in Chennai for level of symptoms (time × site interaction F = 7.36, d.f. = 1.49, P = 0.002, ƞp2 = 0.03), duration of remission (mean 16.1 v. 9.78 months, t = -7.35, d.f. = 331, P < 0.001, Cohen's d = 0.80) and the proportion of patients in remission (81.5% v. 60.3%, χ2 = 16.12, d.f. = 1, P < 0.001). The site differences in outcome remained robust after adjusting for inter-site differences in other characteristics. Early remission and family support facilitated better outcome on negative symptoms. No significant differences were observed in positive symptom outcomes. CONCLUSIONS: Patients with FEP treated in EIS in LMIC contexts are likely to show better outcome on negative symptoms compared with those in HIC contexts. Early remission and family support may benefit patients across both contexts.

Schizophrenia, recovery and the individual-cultural considerations.

OBJECTIVES: The concept of recovery in mental health has been embraced by many services across the world. Placing the individual (self) at the core of service delivery constituted a profound shift from service-driven models of care. However, cultures described as individualistic or collectivist may hold very different views of individuality. In cultures with collectivist orientation, the notion of 'individualism' is integrated into the structure and dynamics of the family. The families in such cultures play a major and lifetime role in caring for its members, making decisions and acting in consideration of the welfare of all. The needs and priorities of individuals, especially women, may be superseded by those of their families. This commentary is on the effect of culture on the identity of self in the recovery process and its relevance to mental health care. CONCLUSION: In multicultural societies like Australia that include Indigenous people, the process of acculturation may be different. For the Indigenous people, the shift was from a collectivist culture to one that was predominantly individualistic. In the provision of recovery-oriented mental health care, there needs to be an awareness of the cultural variations in the relational dynamics of individualism.

The Tamil Version of the Three-Factor Eating Questionnaire-R18V2: Reliability and Factor Structure Among Persons with Schizophrenia.

Background: Persons with schizophrenia (PwS) are vulnerable to developing disordered eating behaviors. However, standardized tools to assess disordered eating patterns are unavailable in the regional language, Tamil. Different versions of the Three-Factor Eating Questionnaire (TFEQ) have been used to measure disordered eating patterns among PwS worldwide. This study aimed to assess the factor structure and reliability of the Tamil version of TFEQ-R18V2 among Tamil-speaking PwS. Methods: Over three months, 135 PwS, aged 18-65 years, who attended the outpatient department of a tertiary mental health service provider in Chennai, completed the Tamil version of TFEQ-R18V2. Thirty PwS completed the tool after two weeks to assess its test-retest reliability. The factor structure of the tool was explored using principal component analysis. Results: The sample included 75 (55.6%) males and 60 (44.4%) females with a mean (±SD) age of 40.1 (±9.8) years and a mean duration of illness of 11.99 (± 8.72) years. Internal consistency and test-retest reliability of the Tamil version were 0.84 and 0.532, respectively. A five-factor structure emerged from the factor analysis, with 65.67% of the variance. Conclusion: The Tamil version of TFEQ-R18V2 emerged as a reliable tool to assess disordered eating patterns among Tamil-speaking PwS.

Patient-reported outcome measures in early psychosis: A cross-cultural, longitudinal examination of the self-reported health and self-reported mental health measures in Chennai, India and Montreal, Canada.

OBJECTIVE: Despite their acknowledged value, patient-reported outcome measures (PROMs) are infrequently used in psychosis, particularly in low-and middle-income countries. We compared ratings on two single-item PROMs, Self-Rated Health (SRH) and Self-Rated Mental Health (SRMH), of persons receiving similar early psychosis services in Chennai, India and Montreal, Canada. We hypothesized greater improvements in SRH and SRMH in the Chennai (compared to the Montreal) sample. METHODS: Participants (Chennai N = 159/168 who participated in the larger study; Montreal N = 74/165 who participated in the larger study) completed the SRH and SRMH during at least two out of three timepoints (entry, months 12 and 24). Repeated measures proportional odds logistic regressions examined the effects of time (baseline to month 24), site, and relevant baseline (e.g., gender) and time-varying covariates (i.e., symptoms) on SRH and SRMH scores. RESULTS: SRH (but not SRMH) scores significantly differed between the sites at baseline, with Chennai patients reporting poorer health (OR: 0.33; CI: 0.18, 0.63). While Chennai patients reported similar significant improvements in their SRH (OR: 7.03; CI: 3.13; 15.78) and SRMH (OR: 2.29, CI: 1.03, 5.11) over time, Montreal patients only reported significant improvements in their SRMH. Women in Chennai (but not Montreal) reported lower mental health than men. Higher anxiety and longer durations of untreated psychosis were associated with poorer SRH and SRMH, while negative symptoms were associated with SRH. CONCLUSIONS: As hypothesized, Chennai patients reported greater improvements in health and mental health. The marked differences between health and mental health in Montreal, in contrast to the overlap between the two in Chennai, aligns with previous findings of clearer distinctions between mind and body in Western societies. Cross-context (e.g., anxiety) and context-specific (e.g., gender) factors influence patients' health perceptions. Our results highlight the value of integrating simple PROMs in early psychosis.

Development and validation of home-based psychosocial self-management interventions in schizophrenia and related disorders in low-resource settings: A mixed methods approach.

Background: Psychosocial interventions, crucial for recovery in patients with schizophrenia, have often been developed and tested in high income countries. We aimed at developing and validating home-based a booklet based psycho-social intervention with inputs from stakeholders: patients, families, and mental health professionals (MHP) for patients with schizophrenia and related disorders in low resource settings. Methods: We developed a preliminary version of psychosocial intervention booklets based on six themes derived from focus group discussions conducted with patients, families, and MHP. Initially, quantitative assessment of content validity was done by MHP on overall and Content Validity Index of individual items of the specific booklets, followed by in-depth interviews about their views. The booklets were modified based on their inputs. Further, pilot testing of manuals was done on the users - nine pairs of patients and caregivers followed by development of a final version of psycho-social intervention. Results: The percentage content validity of individual modules and overall booklets was ≥78.5% indicating good validity. Most MHP reported that the manuals were relevant and easy to use but were text-heavy, and lengthy. On pilot testing of modified manuals with patients and their family caregivers, majority (77.8%) of them found booklets useful and suggested that there should be separate booklets for both patients and caregivers for providing information and entering separate response for the activities, integrating helpful tips. Language should be simple. Finally, two sets of booklets ("info book" and "workbook") named 'Saksham' (meaning empowered) were created with specific modules (viz., 'Medicine adherence', 'Daily routine', 'Eating right', 'Physical activity', 'Physical health monitoring', 'Self-reliance', and 'Psychoeducation') for patients and caregivers each, in two languages (Hindi and English). Conclusion: Booklets with modules for psychosocial interventions for patients with schizophrenia and their caregivers were developed after establishing content validity and pilot testing.

Do past and present adverse experiences impact the mental health of children? A study among children in the Juvenile Justice System in India.

Background: Children in the Juvenile Justice System (JJS) in India include children who may have engaged in criminal acts and children who cannot be cared for by their families of origin for various reasons. Given the nature of the children in such circumstances, they face multiple challenges growing up. Few studies from India have systematically explored interpersonal experiences, including adverse childhood experiences (ACEs) or bullying experiences, and their effects on these children's mental health. Materials and Methods: A cross-sectional study was conducted using standardized scales to identify the frequencies of and relationships between life experiences and current mental health outcomes (stress, well-being, and psychopathology) faced by children residing in seven child care institutions (CCIs) across two states in India. Results: Of the 278 children who participated in the study, at least one ACE was endorsed by 86.7%, and at least one instance of bullying was experienced by 71.7%. A significant negative correlation was noted between the number of ACEs, bullying experiences, and well-being and a significant positive correlation with stress and psychopathology. Information about the family of origin was significantly associated with lower psychopathology and stress scores. Conclusions: This study highlights the relationship between mental health outcomes, ACEs, and bullying experiences in children in the JJS in India. The study identifies the immediate and ongoing effects of these experiences on children's mental health and, thus, focuses on the need for appropriate interventions to allay the effects of these experiences.

The Tamil version of Eating Attitudes Test-26: Reliability and factor structure among persons with schizophrenia.

Background: Disordered eating behaviors (DEBs) among persons with schizophrenia (PwS) have been reported widely in the literature, with very few studies in India. Robust tools to assess DEB are needed in the vernacular language to capture symptoms of disordered eating accurately. No such tools are available in the Tamil language. Globally, the Eating Attitudes Test (EAT-26) is widely used to assess DEB among PwS. Aim: This study aimed to translate and study the factor structure and reliability of EAT-26 among Tamil-speaking PwS. Materials and Methods: EAT-26 was translated into Tamil following the Oxford linguistic validation process. Experts evaluated its face validity and content validity. One hundred and fifty PwS, aged between 18 and 65 years, who attended the outpatient department of a psychiatric facility, and consented to participate, completed the Tamil version of EAT-26. Test-retest reliability of EAT-26 was assessed by readministering the tool to 30 PwS after two weeks. Data were analyzed using Stata 16.1. Internal consistency and test-retest reliability were computed using Cronbach's alpha and intraclass coefficients, respectively. The factor structure of EAT-26 was explored using principal component analysis (PCA). Spearman's rho was calculated to understand the correlation between the factors. Results: EAT-26 had an internal consistency of 0.71 and test-retest reliability of 0.896. Factor analysis revealed nine latent factors consisting of 21 of the original 26 items on EAT-26. These 21 items could explain a variance of 63.63%. Conclusions: The Tamil version of the EAT-26 is a reliable tool to assess DEB among Tamil-speaking PwS. It can be used to screen PwS for eating disorder risk.

Show me you care: A patient- and family-reported measure of care experiences in early psychosis services.

AIM: Despite their emphasis on engagement, there has been little research on patients' and families' experiences of care in early intervention services for psychosis. We sought to compare patients' and families' experiences of care in two similar early psychosis services in Montreal, Canada and Chennai, India. Because no patient- or family-reported experience measures had been used in a low- and middle-income context, we created a new measure, Show me you care. Here we present its development and psychometric properties. METHODS: Show me you care was created based on the literature and stakeholder inputs. Its patient and family versions contain the same nine items (rated on a 7-point scale) about various supportive behaviours of treatment providers towards patients and families. Patients (N = 293) and families (N = 237) completed the measure in French/English in Montreal and Tamil/English in Chennai. Test-retest reliability, internal consistency, convergent validity, and ease of use were evaluated. RESULTS: Test-retest reliability (intra-class correlation coefficients) ranged from excellent (0.95) to good (0.66) across the patient and family versions, in Montreal and Chennai, and in English, French, and Tamil. Internal consistency estimates (Cronbach's alphas) were excellent (≥0.87). The measure was reported to be easy to understand and complete. CONCLUSION: Show me you care fills a gap between principles and practice by making engagement and collaboration as central to measurement in early intervention as it is to its philosophy. Having been co-designed and developed in three languages and tested in a low-and-middle-income and a high-income context, our tool has the potential for global application.

Pathways to care in first-episode psychosis in low-resource settings: Implications for policy and practice.

OBJECTIVE: Developing countries such as India face a major mental health care gap. Delayed or inadequate care can have a profound impact on treatment outcomes. We compared pathways to care in first episode psychosis (FEP) between North and South India to inform solutions to bridge the treatment gap. METHODS: Cross-sectional observation study of 'untreated' FEP patients (n = 177) visiting a psychiatry department in two sites in India (AIIMS, New Delhi and SCARF, Chennai). We compared duration of untreated psychosis (DUP), first service encounters, illness attributions and socio-demographic factors between patients from North and South India. Correlates of DUP were explored using logistic regression analysis (DUP ≥ 6 months) and generalised linear models (DUP in weeks). RESULTS: Patients in North India had experienced longer DUP than patients in South India (ß = 17.68, p < 0.05). The most common first encounter in North India was with a faith healer (45.7%), however, this contact was not significantly associated with longer DUP. Visiting a faith healer was the second most common first contact in South India (23.6%) and was significantly associated with longer DUP (Odds Ratio: 6.84; 95% Confidence Interval: 1.77, 26.49). Being in paid employment was significantly associated with shorter DUP across both sites. CONCLUSIONS: Implementing early intervention strategies in a diverse country like India requires careful attention to local population demographics; one size may not fit all. A collaborative relationship between faith healers and mental health professionals could help with educational initiatives and to provide more accessible care.

Assessing the effectiveness and cost-effectiveness of a solution-focused resource-orientated approach (DIALOG+) to improving the quality of life for people with psychosis in India and Pakistan-a cluster RCT.

BACKGROUND: Severe mental illness (SMI) presents a major challenge worldwide, affecting approximately 5-8% of the world's population. It causes significant distress to affected people, families and wider communities, generating high costs through loss of productivity and ongoing healthcare use. Over 75% of patients with psychosis receive inadequate care and experience a negative financial impact and reduced quality of life (QoL). It is therefore a priority to reduce the treatment gap by providing low-cost, effective interventions for people with psychosis. Our research project, PIECEs, is designed to explore, adapt and test a low-cost, approach (DIALOG+) that makes use of existing resources to improve community-based care for patients with psychosis. The research will be conducted in two urban sites: Karachi, Pakistan and Chennai, India. DIALOG+ is a novel, technology-assisted and resource-oriented intervention, based on QoL research, concepts of patient-centred communication, IT developments and solution-focused therapy. However, the approach has not been rigorously tested within India and Pakistan. Our randomised controlled trial (RCT) aims to test the effectiveness and cost-effectiveness of DIALOG+ in improving the QoL and clinical outcomes for individuals with long-term psychosis being treated in the community in India and Pakistan. METHODS: To assess the acceptability, feasibility, and cost effectiveness of DIALOG+, we will conduct a cluster RCT with 210 patients and 14 clinicians in each country. The intervention will be used during a routine interaction between a clinician and a patient. It consists of a patient-centred assessment (the DIALOG scale) whereby the clinician invites the patient to rate their satisfaction with different life domains and treatment aspects, which forms the active control group. The intervention group will follow this up with a four-step solution-focused approach to identify the patient's resources and develop solutions to deal with the patient's concerns (DIALOG+). DISCUSSION: If shown to be effective DIALOG+ has the potential to improve community-based care and the QoL for millions of people within India and Pakistan who experience psychosis. TRIAL REGISTRATION: The trial was registered prospectively on the ISRCTN Registry: ISRCTN13022816 on 9 February 2022.

Epidemiology of Untreated Psychoses in 3 Diverse Settings in the Global South: The International Research Program on Psychotic Disorders in Diverse Settings (INTREPID II).

Importance: Less than 10% of research on psychotic disorders has been conducted in settings in the Global South, which refers broadly to the regions of Latin America, Asia, Africa, and Oceania. There is a lack of basic epidemiological data on the distribution of and risks for psychoses that can inform the development of services in many parts of the world. Objective: To compare demographic and clinical profiles of cohorts of cases and rates of untreated psychoses (proxy for incidence) across and within 3 economically and socially diverse settings in the Global South. Two hypotheses were tested: (1) demographic and clinical profiles of cases with an untreated psychotic disorder vary across setting and (2) rates of untreated psychotic disorders vary across and within setting by clinical and demographic group. Design, Setting, and Participants: The International Research Program on Psychotic Disorders in Diverse Settings (INTREPID II) comprises incidence, case-control, and cohort studies of untreated psychoses in catchment areas in 3 countries in the Global South: Kancheepuram District, India; Ibadan, Nigeria; and northern Trinidad. Participants were individuals with an untreated psychotic disorder. This incidence study was conducted from May 1, 2018, to July 31, 2020. In each setting, comprehensive systems were implemented to identify and assess all individuals with an untreated psychosis during a 2-year period. Data were analyzed from January 1 to May 1, 2022. Main Outcomes and Measures: The presence of an untreated psychotic disorder, assessed using the Schedules for Clinical Assessment in Neuropsychiatry, which incorporate the Present State Examination. Results: Identified were a total of 1038 cases, including 64 through leakage studies (Kancheepuram: 268; median [IQR] age, 42 [33-50] years; 154 women [57.5%]; 114 men [42.5%]; Ibadan: 196; median [IQR] age, 34 [26-41] years; 93 women [47.4%]; 103 men [52.6%]; Trinidad: 574; median [IQR] age, 30 [23-40] years; 235 women [40.9%]; 339 men [59.1%]). Marked variations were found across and within settings in the sex, age, and clinical profiles of cases (eg, lower percentage of men, older age at onset, longer duration of psychosis, and lower percentage of affective psychosis in Kancheepuram compared with Ibadan and Trinidad) and in rates of untreated psychosis. Age- and sex-standardized rates of untreated psychoses were approximately 3 times higher in Trinidad (59.1/100 000 person-years; 95% CI, 54.2-64.0) compared with Kancheepuram (20.7/100 000 person-years; 95% CI, 18.2-23.2) and Ibadan (14.4/100 000 person-years; 95% CI, 12.3-16.5). In Trinidad, rates were approximately 2 times higher in the African Trinidadian population (85.4/100 000 person-years; 95% CI, 76.0-94.9) compared with the Indian Trinidadian (43.9/100 000 person-years; 95% CI, 35.7-52.2) and mixed populations (50.7/100 000 person-years; 95% CI, 42.0-59.5). Conclusions and Relevance: This analysis adds to research that suggests that core aspects of psychosis vary by historic, economic, and social context, with far-reaching implications for understanding and treatment of psychoses globally.

Implementing psychosocial interventions within low and middle-income countries to improve community-based care for people with psychosis-A situation analysis.

Background: Globally, a treatment gap exists for individuals with severe mental illness, with 75% of people with psychosis failing to receive appropriate care. This is most pronounced in low and middle-income countries, where there are neither the financial nor human resources to provide high-quality community-based care. Low-cost, evidence-based interventions are urgently needed to address this treatment gap. Aim: To conduct a situation analysis to (i) describe the provision of psychosocial interventions within the context of existing care in two LMICs-India and Pakistan, and (ii) understand the barriers and facilitators of delivering a new psychosocial intervention. Method: A situation analysis including a quantitative survey and individual interviews with clinicians, patients and caregivers was conducted. Quantitative survey data was collected from staff members at 11 sites (private and government run hospitals) to assess organizational readiness to implement a new psychosocial intervention. To obtain in-depth information, 24 stakeholders including clinicians and service managers were interviewed about the typical care they provide and/or receive, and their experience of either accessing or delivering psychosocial interventions. This was triangulated by six interviews with carer and patient representatives. Results and discussion: The results highlight the positive views toward psychosocial interventions within routine care and the enthusiasm for multidisciplinary working. However, barriers to implementation such as clinician time, individual attitudes toward psychosocial interventions and organizational concerns including the lack of space within the facility were highlighted. Such barriers need to be taken into consideration when designing how best to implement and sustain new psychosocial interventions for the community treatment of psychosis within LMICs.

Whose responsibility? Part 2 of 2: views of patients, families, and clinicians about responsibilities for addressing the needs of persons with mental health problems in Chennai, India and Montreal, Canada.

BACKGROUND: Individuals with mental health problems have many insufficiently met support needs. Across sociocultural contexts, various parties (e.g., governments, families, persons with mental health problems) assume responsibility for meeting these needs. However, key stakeholders' opinions of the relative responsibilities of these parties for meeting support needs remain largely unexplored. This is a critical knowledge gap, as these perceptions may influence policy and caregiving decisions. METHODS: Patients with first-episode psychosis (n = 250), their family members (n = 228), and clinicians (n = 50) at two early intervention services in Chennai, India and Montreal, Canada were asked how much responsibility they thought the government versus persons with mental health problems; the government versus families; and families versus persons with mental health problems should bear for meeting seven support needs of persons with mental health problems (e.g., housing; help covering costs of substance use treatment; etc.). Two-way analyses of variance were conducted to examine differences in ratings of responsibility between sites (Chennai, Montreal); raters (patients, families, clinicians); and support needs. RESULTS: Across sites and raters, governments were held most responsible for meeting each support need and all needs together. Montreal raters assigned more responsibility to the government than did Chennai raters. Compared to those in Montreal, Chennai raters assigned more responsibility to families versus persons with mental health problems, except for the costs of substance use treatment. Family raters across sites assigned more responsibility to governments than did patient raters, and more responsibility to families versus persons with mental health problems than did patient and clinician raters. At both sites, governments were assigned less responsibility for addressing housing- and school/work reintegration-related needs compared to other needs. In Chennai, the government was seen as most responsible for stigma reduction and least for covering substance use services. CONCLUSIONS: All stakeholders thought that governments should have substantial responsibility for meeting the needs of individuals with mental health problems, reinforcing calls for greater government investment in mental healthcare across contexts. The greater perceived responsibility of the government in Montreal and of families in Chennai may both reflect and influence differences in cultural norms and healthcare systems in India and Canada.

Adapting, updating and translating the Social Functioning Scale to assess social, recreational and independent functioning among youth with psychosis in diverse sociocultural contexts.

AIM: To compare social, recreational and independent functioning among persons with psychosis across two geo-cultural contexts, we adapted the well-established Social Functioning Scale (SFS) and translated it into French and Tamil. We present the development and psychometric testing of this adaptation, the SFS-Early Intervention. METHODS: Sixteen items were added to reflect contemporary youth activities (e.g., online games) and 31 items adapted to enhance applicability and/or include context-specific examples (e.g., 'church activity' replaced with 'religious/spiritual activity'). Psychometric properties and participant feedback were evaluated. RESULTS: Test-retest reliability (ICCs) ranged from 0.813 to 0.964. Internal consistency (Cronbach's α) ranged from .749 to .936 across sites and languages. Correlations with original subscales were high. The scale was rated easy to complete and understand. CONCLUSIONS: The SFS-Early Intervention is a promising patient-reported measure of social, recreational and independent functioning. Our approach shows that conceptually sound existing measures are adaptable to different times and contexts.

Situational analysis of prevailing practices in the management of first-episode psychosis in Chennai, India.

AIM: This paper aims to examine how existing mental health within the city of Chennai, India manages first-episode psychosis, to determine lacunae and barriers in providing effective early intervention and to make appropriate recommendations to improve the care of first-episode psychosis patients. METHODS: Interviews were held with 15 health professionals to capture information on current practices and facilities available for the management of first-episode psychosis. RESULTS: No specialized clinic or services were available for individuals with first-episode psychosis in Chennai, except one. Pharmacotherapy was the main treatment modality with psychological support to patients and families. Most common drugs used were Risperidone, Olanzapine, and Haloperidol in their recommended doses. General practitioners and paediatricians, due to inadequate training in mental health, referred patients with psychosis to mental health professionals. CONCLUSIONS: Equipping the existing mental health services to manage FEP and training all health professionals on psychosis will improve FEP management in Chennai.