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.

An appraisal of psychotherapy training during psychiatry residency program in India: A national survey.

Background: The need for psychotherapy training (PT) has been recognized worldwide and is considered an integral component of postgraduate psychiatry training. Our study aims to assess the quality of PT received by psychiatrists during their postgraduate studies and its impact on their current practice. Aim: To evaluate the quality of PT and its effect on the current psychiatry practice. Methodology: An anonymous web-based survey was conducted on registered psychiatrists practicing in India to evaluate the level and quality of PT received during their postgraduate studies. Results: The survey indicates that PT was included in the postgraduate psychiatry curriculum (73.8%). However, more than 50% of responders reported no separate posting, evaluation, logbook, or guidelines related to PT. Most (95.4%) psychiatrists think their PT could have been better. PT was satisfying in medical colleges in terms of inclusion in the curriculum (7.70, P = .021), psychotherapy rotations (16.48, P = <0.001), supervision of sessions (14.80, P = 0.001), lectures on psychotherapy (10.13, P = 0.006), periodic psychotherapy meet/forum (19.35, P = <0.001), maintenance of psychotherapy logbook/records (7.65, P = 0.022), institutional or departmental guideline related to PT (20.55, P = <0.001), and overall quality of PT (22.05, P = .005 and 31.81, P = <.001). Time constraint is the most common (49.9%) barrier in delivering psychotherapy. Conclusion: PT is not well organized, consistent, and uniform in psychiatry training; there is a prevailing sense of inadequacy and dissatisfaction among the country's psychiatrists with a perceived need to improve and learn PT.

Role of humanities in modern medical education.

PURPOSE OF REVIEW: The role and importance of integrating humanities into medical education has been recognized for a long time. However, to what extent humanities are included in the medical curricula and how and when they are taught during the medical training in medical schools across the world is unclear. The review was undertaken to study the current status and role of humanities in medical education. RECENT FINDINGS: Humanities content in the medical curriculum and the teaching of humanities continue to remain unstandardized. What constitutes medical humanities is unclear as there are several understandings of medical humanities. The benefits and value - both short term and long term - of including humanities in training of doctors and other health professionals remain unresolved and continue to be debated. Although some surveys have shown that exposure to the humanities was significantly correlated with positive personal qualities, including empathy, tolerance for ambiguity, wisdom, emotional appraisal, self-efficacy, and spatial skills, and inversely correlated with some components of burnout, robust evidence from well conducted studies to support the benefits of integrating humanities into medical training is very limited. An overreaching conceptual or theoretical framework for the health humanities in health professionals' education continue to be elusive. SUMMARY: The status, stature, profile, and role of humanities in medical education remain varied across medical schools and universities. There is a need for standardized curricula, uniform criteria and guidelines for teaching medical humanities, training modules / materials, methods of assessment and better integration of humanities in medical education.

Challenges in tracing treatment non-adherent persons with mental illness: Experiences from a rural community mental health center, India.

Identification, enrollment, and retention in treatment are challenging processes in mental health care. The present paper highlights the challenges in tracing and reenrolling non-adherent persons with mental illness for treatment in a rural community mental health center. Unclear address, phone numbers not in use, relocation from the given address, no further contact details etc. are the barriers to trace and make the home visits. A detailed review of the medical record, having a network with the village informal health care workers and groups, utilizing peer group support, etc., are the facilitators for tracing the treatment non-adherent persons in the community.

Treatment non-adherence pattern among persons with neuropsychiatric disorders: A study from a rural community mental health centre in India.

BACKGROUND: Treatment gap causes significant loss to individuals, families, societies and the nation. Treatment adherence enhancement is a major challenge in psychiatric disorders. Globally, the community mental health services are obligated to minimize the treatment and adherence gap. In recent years' retrospective studies are gaining importance to measure the trend of mental health service utilization, cost effectiveness, resources allocation and similar aspects. AIM: To explore the treatment adherence pattern of persons with neuropsychiatric illness from a rural community mental health centre. METHOD: Five hundred and ninety-six medical records of persons with neuropsychiatric disorders who registered for outpatient treatment between 2015 and 2017 at Sakalawara Rural mental health centre of National Institute of Mental Health and Neuro Sciences, Bangalore, India, were reviewed to understand their adherence pattern. RESULTS: Out of 596 patients, 68 (11.4%) were referred to tertiary care mental health and District Mental Health Programme (DMHP) services. Out of the remaining 528 patients, 29.7% were regular to mental health services over a period of 12 months and above; majority of the patients (36.2%) dropped out of their treatment after their first contact and 34.1% discontinued their follow up visits over a period of first week to 12 months. CONCLUSION: Community based mental health centres too face challenges of and problems related to treatment non-adherence. Persons with neuropsychiatric disorders require continuity of care through regular home visits, out-reach services and innovative methods which will enhance treatment adherence.

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.

Overview of behavioural and psychological consequences of COVID 19.

PURPOSE OF REVIEW: The paper aims to provide an overview of the psychological and behavioural impacts of the COVID-19 pandemic, with a focus on variations in behavioural response in different geographical areas due to the existence of different social-cultural contexts. RECENT FINDINGS: Whilst anxiety, depression and economic stressors are common findings worldwide, specific behavioural responses are heavily influenced by government stances, misinformation, conspiratorialism and competing demands of resource scarcity. This has led to very different understandings of the pandemic even in geographically close areas, and more so when comparing disparate regions such as Africa, South America and Europe. The paper also comments on the absence of robust evidence regarding increases of suicidality and violence on a global level, whilst noting evidence certainly exists in specific regions. SUMMARY: The psychological and behavioural impact of COVID is heavily influenced by the local lens. Beyond a very broad brush approaches, expected behaviours from one area cannot easily be extrapolated to others. Where possible, clinicians should be guided by local data, ideally placing expectations of responses in a cultural context.

Mental health impact of COVID-19: Australian perspective.

Australia's response to the coronavirus outbreak has widely been considered to be among the most successful in the world. A bipartisan "national government" akin to that in wartime, a fairly unified COVID response by the federal and all the state governments, international border closures and quarantine, some of the best coronavirus testing in the world, and widespread public acceptance of physical distancing, all contributed to Australia being able to call itself the "lucky country" in its successful navigation of the COVID crisis. The country clearly had a plan for the mental health consequences of COVID. The impacts of lockdown were identified early, and steps taken to mitigate them. There was no spike in tertiary mental health presentations. Telehealth was embraced, support services mobilized, and public awareness of mental health issues made part of the conversation. While anxiety seemed raised nationwide, much of this lays at a subclinical level, manifesting through activities such as increased consumption of alcohol. Management of the burden of increased nationwide anxiety was carried out through online-based nongovernmental organizations, often directly recommended by the government itself.

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.

Psychiatry postgraduate examinations for 2020 in the middle of COVID19 crisis: Suggestions from Indian teachers of psychiatry.

The COVID19 pandemic is an unprecedented disaster. In India, the spread of COVID19 infection and the subsequent lockdown coincided with a crucial period of the annual examination in almost all educational institutions. The pandemic has created hurdles in the conduct of examination due to many reasons, some of which are spread of infection and associated safety issues, lack of public transport for patients as well as the postgraduates in outstation and examiners, and lack of workforce due to round-the-clock service for rendering health services leading to difficulty in arranging logistics at the examination center. Currently, there are no guidelines or policies on how examinations need to be carried out during such a pandemic. Hence, there is an urgent need to look at solutions within the profession for the completion of examination. Teachers of psychiatry play an important role in the national mental health services. Their expertise can be valuable for finding solutions that work. This article has compiled suggestions from Indian teachers of psychiatry.

Postgraduate training in psychiatry in Asia.

PURPOSE OF REVIEW: To understand the current situation, needs and challenges in the area of postgraduate training in psychiatry in Asia and identify implementable solutions.Leaders in psychiatric education from nine Asia Pacific countries prepared country reports, based on a suggested list of items and met for a day to discuss and identify implementable solutions to improve the current unsatisfactory status of postgraduate training in psychiatry. RECENT FINDINGS: Except Japan, all the other countries have a very low number of psychiatrists per 100 000 population - far lower than the global target of 10 psychiatrist per 100 000 population. The undergraduate teaching in psychiatry in majority of the countries is restricted to 20 h of lectures given during the 4-6 semester and 2-3 weeks of clinical ward placements. The duration as well as the overall quality of postgraduate training and methods of assessment and accreditation varies widely across and within countries. SUMMARY: Numerous gaps that need to be addressed to enhance the quality of psychiatrists trained in Asia were identified. There is a need to have uniform minimum standards of training and mechanisms of mutual support, for not only training but also academics and research activities in Asia.

Are somatoform disorders 'mental disorders'? A contribution to the current debate.

PURPOSE OF REVIEW: During the last 2 years, a debate has started over whether the somatoform symptoms/medically unexplained symptoms are wrongly placed under the category of mental disorders (section F in International classification of diseases-10 and in Diagnostic and statistical manual for mental disorders-IV). RECENT FINDINGS: Most experts on medically unexplained symptoms agree that there is a substantial need for revision of the diagnoses of somatoform disorders. While some authors suggest moving the somatoform disorders from axis I to axis III, others suggest improving the classification of these syndromes on axis I, such as by using empirically derived criteria and by introducing psychological descriptors which justify the categorization as a mental disorder. In contrast to the situation when the last version of Diagnostic and statistical manual for mental disorders was published, new empirical data has shown some psychological and behavioural characteristics of patients with somatoform symptoms. These and other empirically founded approaches can be landmarks for the revision of this section in Diagnostic and statistical manual for mental disorders-V and International classification of diseases-11. SUMMARY: The classification of somatoform disorders as 'mental disorders' could be justified if empirically founded psychological and behavioural characteristics are included into the classification process. Attention focusing, symptom catastrophizing, and symptom expectation are outlined as possible examples of involved psychological processes.

Schizophrenia outcome measures in the wider international community.

BACKGROUND: Outcome of schizophrenia has been described as favourable in low- and middle-income countries. Recently, researchers have questioned these findings. AIMS: To examine the outcome studies carried out in different countries specifically looking at those from low- and middle-income countries. METHODS: Long-term course and outcome studies in schizophrenia were reviewed. RESULTS: A wide variety of outcome measures are used. The most frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/occupational functioning, marriage, social support and burden of care (indirect indicators). Areas such as cognitive function, duration of untreated psychosis, quality of life and effect of medication have not been widely studied in low- and middle-income countries. CONCLUSIONS: The outcome of schizophrenia appears to be better in low- and middle-income countries. A host of sociocultural factors have been cited as contributing to this but future research should aim to understand this better outcome. There is a need for more culture-specific instruments to measure outcomes.