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.

A study of collaborative telepsychiatric consultations for a rehabilitation centre managed by a primary healthcare centre.

BACKGROUND & OBJECTIVES: : Telepsychiatric methods can be used for the purpose of providing clinical care comparable to in-person treatment in various settings including rehabilitation. Previous evidence has shown that clinical outcomes for both are comparable. In view of challenges posed in the implementation of traditional psychiatric care in India, telepsychiatry offers an avenue to provide feasible, affordable and clinically useful psychiatric services. This study was conducted to examine the utility, feasibility and clinical effectiveness of providing collaborative telepsychiatric services with a primary care doctor for inpatients in a rehabilitation centre through a telepsychiatrist of estabilished psychiatry department in a tertiary care centre in south India in a collaborative care model with a primary care doctor. METHODS: : Patients at the rehabilitation centre attached to an urban primary healthcare centre received collaborative care using telepsychiatry for a period from January 2013 to December 2016. A retrospective review of their charts was performed and sociodemographic, clinical and treatment details were collected and analyzed. RESULTS: : The sample population (n=132) consisted of 75 per cent males, with a mean age of 43.8 ± 12.1 yr. Each patient received an average of 7.8 ± 4.9 live video-consultations. Initially, an antipsychotic was prescribed for 84.1 per cent (n=111) of patients. Fifty four patients (40.9%) had a partial response and 26 (19.7%) patients showed a good response. INTERPRETATION & CONCLUSIONS: : The study sample represented the population of homeless persons with mental illness who are often brought to the rehabilitation centre. This study results demonstrated the successful implementation of inpatients collaborative telepsychiatry care model for assessment, follow up, investigation and treatment of patients through teleconsultation.

Proxy consultations for severe mental illnesses: An exploratory cross-sectional study from a tertiary care hospital.

BACKGROUND: Non-adherence to medication leading to a break in continuity of care poses significant challenges in severe mental illness (SMI), leading to poor outcomes. In India, proxy consultation, wherein caregivers consult on behalf of patients, is a commonly adopted but insufficiently researched area to address these challenges. AIMS: To explore the extent of proxy consultation in outpatient care of persons with SMI and investigate its sociodemographic and clinical correlates. METHODOLOGY: In a tertiary care psychiatry outpatient setting, we conducted a cross-sectional study involving 374 caregivers of persons with SMI (Schizophrenia, Bipolar and related disorders). Descriptive statistics and univariate logistic regression were performed to examine correlates' relationships with proxy consultation. RESULTS: Proxy consultation prevalence was 43% in the past 1 year. Compared with 18 to 30 years, middle-aged patients aged 31 to 40, 41 to 50 and 51 to 60 years had twofold, threefold and sixfold increased chances of proxy consultation, respectively. Being illiterate had six times higher odds than graduates, three times and two times if they studied till primary and secondary education. Early age of onset was associated with three times higher chances of proxy consultation compared to the onset of illness in adulthood. On the contrary, male gender and upper and middle socioeconomic status decreased the chances of proxy consultation by 40%. Financial difficulties (n = 72, 45%) and patients' unwillingness to visit outpatients (n = 44, 27.5%) were the most commonly cited reasons for proxy consultation. CONCLUSION: Proxy consultations are relatively common, driven by many social, economic, patient-related, pragmatic and practical factors. In formulating community care policies for persons with SMI, the primary imperative should be to conduct additional research, deepening our understanding of proxy consultations. Additionally, it is essential to be mindful of the diverse issues associated with proxy consultations during the formulation process.

Suicide attempts in schizophrenia - A large retrospective cohort study from a tertiary care psychiatry centre in India.

The extent of variability in identified risk factors for suicide attempts (SA) in schizophrenia limits their generalization. This study aimed to identify the rates and associated correlates of SA in schizophrenia by reviewing a large cohort (n=500). Nearly one-fourth had a history of SA, which was independently associated with a family history of SA, more inpatient admissions, and better long-term treatment response. These findings highlight the complex interaction between biological factors influencing SA and illness determinants in schizophrenia. Furthermore, they reinforce the need for future research to unravel the association between suicide vulnerability and the pathophysiology of schizophrenia to attenuate morbidity and mortality associated with the same.

Continuing professional development proposed guidelines of national medical commission, India - A critique.

The National Medical Commission 'Ethics and Medical Registration Board' (EMRB) proposed 'The registered Medical Practioner (Professional Conduct) Regulations' 2022 on 23.05.2022 for public opinion. One of the major regulations included Continuing Professional Development (CPD) Guidelines in Chapter 2, Section 5. The main objective of the CPD Guidelines is to upgrade knowledge and skills regularly and ensure compliance with existing guidelines by the Registered Medical Practitioner (RMP) under NMC. The drafted CPD guidelines provide a framework for uniform, clear, and structured CPD modules for both in-person conferences and online webinars as well as accreditation. The proposed CPD guideline will ensure adequate up-gradation of knowledge, along with the improved quality of the content of CPD. This article aims to map the trajectory of CPD on its roads from origin to becoming a reality in the Indian scenario as well as identify the challenges and opportunities in implementing CPD in India.

Fitness to re-join job: Neuropsychiatric perspective.

Objectives: Evaluating "Fitness to Re-join Job" and certification in persons with Neuro-Psychiatric Disorders is an indispensable professional responsibility. However, there is little documented guidance on clinically approaching this particular issue. This study aimed to study the sociodemographic, clinical, and employment profile of patients who sought fitness to re-join their job from the tertiary neuropsychiatric center. Materials and Methods: This study was carried out at the National Institute of Mental Health and Neurosciences in Bengaluru, India. A retrospective chart review was adapted for the purpose. One hundred and two case files referred to medical board for fitness to rejoin the duty were reviewed from January 2013 to December 2015. Apart from the descriptive statistics, the Chi-square test or Fisher exact test was used to test the association between categorical variables. Results: Patients' mean (standard deviation) age was 40.1 (10.1) years; 85.3% were married, and 91.2% were male. Common reasons for seeking "fitness certification" were work absenteeism (46.1%), illness affecting the work (27.4%), and varied reasons (28.4%). The presence of neurological disorders, sensory-motor deficits, cognitive decline, brain damage/insult, poor drug compliance, irregular follow-ups, and poor or partial treatment response were associated with an unfitness to rejoin the job. Conclusion: This study shows that work absenteeism and the impact of illness on work are common reasons for referral. Irreversible neurobehavioural problems and deficits impacting work are common reasons for unfitness to rejoin the job. There is a need for a systematic schedule to assess the fitness for the job in patients with neuropsychiatric disorders.

Study on covert administration of medications practices among persons with severe mental illness: A cross-sectional study.

BACKGROUND: Covert administration of medication (CoAdM) by caregivers to persons with severe mental illness (SMI) is a commonly observed medication delivery practice in India. AIMS: This study aims to examine different medication delivery practices adopted by caregivers to provide care to SMI at times of medication refusal. METHOD: This study was conducted at the outpatient department between April 2019 and November 2019. A semi-structured questionnaire was used to interview the caregivers of persons with SMI to assess medication delivery practices. RESULTS: A total of 300 caregivers were interviewed. CoAdM was practiced in 96 (32.0%) persons with SMI at least once during their lifetime, and other strategies used were pleading (n = 105, 35.0%), lying (n = 10, 3.3%), and threatening (n = 154, 51.4%). Logistic regression showed that male gender (OR 4.75; CI 1.37-16.46), absent insight (OR 10.0; CI 2.01-47.56), and poor adherence to medication (OR 4.75; CI 1.31-16.92) were significantly associated with CoAdM in the last 1 year. Caregivers perceived significant improvement in self-care (Z = -4.37, p < .01), interpersonal (Z = -7.61, p < .01), work (Z = -5.9, p < .01), family functioning (Z = -7.82, p < .01) difficult behavior (Z = -8.27, p < .01), and dependency (Z = -6.34, p < .01) in persons with SMI with use of CoAdM. CONCLUSIONS: CoAdM was given to one in three persons with SMI at some point in their lives. Male gender, absent insight and poor adherence were predictive of CoAdM in the last 1 year. Caregiver perceived improvements in self-care, work, interpersonal, family functioning, problem behaviors, and dependency after CoAdM. Policies need to be evolved to serve all stakeholders while keeping these practices in mind.

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

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

Predictors of future suicide attempts in individuals with high suicide risk admitted to an acute psychiatry suicide intervention unit in India. A survival analysis study.

OBJECTIVE: Determination of suicide vulnerability remains challenging in mental illness. Variability in risk factors identified compound its poor predictability. Longitudinal studies, offering more reliable indices of risk, from developing countries are conspicuously limited. Furthermore, research advances allude to inherent vulnerability. This study, the first of its kind from India, consequently aimed to delineate factors influencing subsequent attempts in mental illness and acute suicidality. METHOD: Baseline and follow-up information (up to five years) was obtained from medical records of individuals (n = 130) with acute suicidality [recent attempt (first attempt/ reattempt) and high-risk ideators]. Variables were compared between individuals with, and without subsequent suicide attempts. Time to attempt and factors influencing the same was determined using survival analysis, and Cox proportional hazard for estimating the likelihood of a subsequent suicide attempt. RESULTS: Median duration of follow up of the sample (n = 130) was 23 months. The sample comprised of individuals with a recent attempt (first-time attempt), recent reattempt and recent high-risk ideators. Subsequent suicide attempts were noted in 30 (23.1 %) patients. Baseline sociodemographic and clinical variables, including suicidality, could not differentiate individuals with a subsequent suicide attempt. Survival analysis indicated that 65 % of subsequent attempts occurred within 9 months of discharge. Family history of suicide and the presence of impulsive-aggressive traits were associated with both, reduced survival time and overall increased risk of a subsequent suicide attempt. CONCLUSION: This study delineates both, the time frame associated with greatest risk, as well as individuals most likely to reattempt suicide. It thereby offers insights into potential windows of opportunity to mitigate prospective suicide risk. Strategies such as enhanced after-care and integrating specific interventions to attenuate impulsive-aggressive behaviors could be a focus to prevent future attempts, thereby decreasing rates of suicide amongst those with mental illness. Furthermore, the findings of this study reaffirm the role of factors that independently confer vulnerability to suicide. Traversing noted regional variations, the findings importantly reinforce the distinct pathophysiological underpinnings of suicide in mental illness.

Care at door-steps for persons with severe mental disorders: A pilot experience from Karnataka district mental health program.

BACKGROUND: Public funded outreach services for persons with severe mental disorders (SMDs), a norm in developed nations, is non-existent in India. We share our pilot experience with an indigenous model named 'Care at Doorsteps' (CADs) for persons with SMDs who dropped out from clinical care of District Mental Health Program (DMHP) at three sites of Karnataka, a south Indian state. AIM: The objectives of this study were to identify the reasons for drop outs from routine care and to assess the burden of illness and disability after the intervention. METHODOLOGY: Six-month prospective observational study on patients aged 18-60 years, diagnosed as Schizophrenia or bipolar disorder was conducted. Three home visits were made by the team and provided medications, also offered brief psychoeducation and counselling. Care-givers were interviewed to identify the reasons for drop outs and their expectations from the treating team. Patients were also assessed using the Clinical Global Impression Scale (CGI), Indian Disability Evaluation and Assessment Scale (IDEAS) and Burden Assessment Schedule (BAS) during each visit. RESULTS: Ninety-six patients (50 males and 46 females) were followed up, of which 85 had a diagnosis of schizophrenia and 11 with bipolar illness. Common reasons for drop out were: single caregiver (breadwinner) unable to accompany the patient, loss of faith in medical treatment and financial constraints. Symptomatic improvement and restoration of productive work were the priority expectations. Over the course, the mean CGI-S showed significant reduction (4.81 ± 1.57, 4.46 ± 1.32 and 4.11 ± 1.39 respectively; p = 0.001). Mean score on BAS showed a significant reduction (85.76 ± 12.15, 83.46 ± 11.30, 84.27 ± 11.82; p = 0.04). Mean total IDEAS scores did not show significant change (13.27 ± 4.78, 12.82 ± 4.24, 13.17 ± 4.40; p = 0.16). CONCLUSION: Meaningful assertive outreach care is feasible in India and is found to be useful for persons with SMDs by utilising the already existing public sector resources.

Assessment of the Financial Capacity in Elderly: Approach and Challenges in Indian Scenario.

The elderly population, with those individuals above the age of 60 years, is increasing exponentially, attributable to higher life expectancy as a result of improved health care, socioeconomic level, and quality of life. As they grow older (>80 years), it becomes difficult to manage their basic needs and daily living. A report on Decade of Healthy Ageing estimates that 14% of people aged 60 years and above cannot meet their basic daily needs which include the ability to manage finances. Some elderly people depend on others to manage finances because of their inability to make decisions resulting in conflicts and communication problems between siblings and other members of the family and lodging of civil lawsuits in India's joint family unit. So, decision-making is an important area to assess in the elderly people, given its clinical, legal, and ethical aspects. Courts of law can refer to older persons for assessing their capacity to manage finances, though there are no structured clinical procedures to assess it in India. This article evaluates existing methods around the world, discusses the challenges associated with the assessment, and provides clinicians with guidance on assessing financial capacity from an Indian perspective.

Approach to Management of Wandering in Dementia: Ethical and Legal Issue.

Wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. Ethical and legal issues especially in the light of the new Indian Mental Healthcare Act of 2017, related to confinement by family members in their homes by family caregivers, seclusion, physical or chemical restraints, other pharmacological and behavioral treatment, highlighting their effectiveness as well as adverse consequences are discussed. This article attempts to address an approach in managing wandering behavior in PwD in light of MHCA, 2017.

Suicide in the context of COVID-19 diagnosis in India: Insights and implications from online print media reports.

BACKGROUND: Suicide reports during the COVID pandemic is an increasing cause for concern. However, there is a limited understanding of suicide among individuals with positive/suspected COVID diagnosis specifically. Hence, this study, using online newspaper reports, aimed to determine factors influencing suicide among individuals withCOVID-19 infection status. METHODOLOGY: Information regarding positive/suspected COVID related suicide was obtained from online newspapers published in 4 languages between 30th Jan 2020 to 16th August 2020 using google news aggregator. Of 235 online identified, 93 were eligible for analysis after the exclusion and analysed using descriptive statistics. RESULTS: Median Age of COVID related suicide victims was 45 years (range 15 - 80) wherein 61.3% belonged to 30-59 year age group, and 75.3% were males. 50% of suicides occurred within the first week of COVID diagnosis confirmation, and 50% suicides occurred at COVID centres. Hanging (53.8%) was the commonest method of suicide, followed by jumping (12.9%). CONCLUSION: Higher risk for suicide was observed among male gender and those with positive/suspected COVID infection within the first week, while receiving treatment in COVID care centres. Hanging and jumping were the two commonest methods. The above highlight an urgent need to integrate suicide preventive strategies into standard care protocols of COVID-19 positive and suspected cases.

Homeless persons with mental illness and COVID pandemic: Collective efforts from India.

COVID-19 pandemic had made an unprecedented impact worldwide. India has entered into a total lockdown by invoking the special provision of Epidemic Diseases Act of 1897 and Disaster Management Act, 2015. The complete lockdown policy has a direct and indirect impact on Homeless Persons with Mental Illness (HPMI) concerning shelter, basic needs and access to health care, besides the transmission of COVID infection. In this manuscript, we highlight the collective efforts undertaken by both the Government and Civil Society in providing care and protection to HPMI against COVID during the lockdown in India.

Approach to Informed Consent in Telepsychiatric Service: Indian Perspective.

Consent is an essential and important medico-legal prerequisite for a patient's treatment. This necessitates the service provider to participate in the informed consent process and discuss the risk-benefit of the proposed treatment, the best available treatment, engage in shared decision-making process, opportunity to convey their view and thereby limit chances of legal liability for all parties. The clinician should have ample knowledge and skill pertaining to the informed consent process and also have adequate understanding of medical ethics and law. This article provides an overview on informed consent pertaining to telepsychiatric services in India.

Setting Up and Providing Telepsychiatry Services in India.

The exponential growth of technology in the past few decades has benefitted the healthcare sector. Telemedicine is a newer advancement which is making healthcare affordable and more accessible to the needy in recent times. This article discusses how to set up telepsychiatry services, the procedure of telepsychiatry consultation, how to record and maintain the electronic health records, the potential challenges, ethical and legal aspects concerning telepsychiatry while ensuring the good practice guidelines, medical ethics, patient rights, and the minimum requirements as established by the Information Technology Act and the telemedicine practice guidelines (TPG) 2020 issued by the Indian Medical Council.

Economic Perspectives on Setting up and Running Telepsychiatry Services in India.

BACKGROUND: Telemedicine Practice Guidelines, 2020 and Telepsychiatry Operational Guidelines, 2020 can be potential game changers in the practice of medicine in India. They provide legal grounds for the practice of telemedicine. The economics of setting up and running telepsychiatry services vis-à-vis in-person services in India is discussed in this paper to aid the practitioners in understanding the costs involved in each of these modalities. METHODS: Costs for various hardware, software, real estate, and human resources are collated from various sources. Telepsychiatry vs. in-person setup is compared for the costs involved. RESULTS: Telepsychiatry consultation will cost much lesser to that of in-person consultation. CONCLUSIONS: Telepsychiatry is an economically viable option. There are many benefits and hurdles in telepsychiatry practice. It is a step towards providing psychiatric services at the doorstep in compliance with the Mental Healthcare Act 2017, upholding the rights of persons with mental illness. It will benefit the practitioner, the patient, and the society.

A Collaborative Tele-Neurology Outpatient Consulation Service in Karnataka: Seven Years of Experience From a Tele-Medicine Center.

BACKGROUND: Neurology services in rural and semi-urban part of India are very limited, due to poor infrastructure, resources, and manpower. Tele-neurology consultations at a non-urban setup can be considered as an alternative and innovative approach and have been quite successful in developed countries. Therefore, an initiative to bridge this health gap through Tele-Medicine has been taken by the Government of India. AIM: To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Neurology consultations from the Tele-Medicine Centre, National Institute of Mental Health and Neurosciences, Bengaluru. METHODOLOGY: We reviewed case files of such patients between December 2010 and March 2017. A total 189 collaborative tele-neurology outpatient consultations were provided through the Tele-Medicine Centre, located at a tertiary hospital-based research centre in southern India. RESULTS: The mean age of the patients was 39.6 (±19) years and 65.6% were aged between 19 to 60 years; 50.8% were male. The most common diagnosis was a seizure disorder in 17.5%, followed by cerebrovascular accident/stroke in 14.8%. Interestingly, 87.3% were found to benefit from tele-neurology consultations using interventions such as a change of medications in 30.1%, referral to a specialist for review in 15.8%, and further evaluation of illness and inpatient care for 7.93%. CONCLUSION: This study has demonstrated the successful implementation of outpatient-based collaborative tele neurology consultation in Karnataka.

Approach to and practical challenges in certification in Psychiatry.

Psychiatrists and mental health professionals (MHPs) are often requested to provide a certificate in connection with admission, treatment, fitness, competence, administration, legal proceedings, or welfare measures and benefits for persons with mental illness. The role of Psychiatrist and MHPs in providing a certificate is an integral part of clinical practice and more so with the implementation of the Mental Healthcare Act, 2017 (MHCA 2017). While issuing a certificate, keeping patient information confidential is a challenging task for a professional as the patient care in psychiatry involves multiple stakeholders (Central and State Mental Health Authorities, Mental Health Review Board, MHPs including psychiatrist, and caregivers). There is limited training at undergraduate or postgraduate level in documentary practices and certification. This article tries to address some of the issues related to certification, professional and legal accountability, and attempts to remove some of the ambiguities associated with the certification process in psychiatry.