Development of A Suicide Prevention Training Module for Social Work Students in India.

Introduction: Social workers constitute a significant task force that serves diverse populations experiencing psychosocial challenges in their daily lives. Lack of suicide prevention content/training in the Master of Social Work program may affect the student's self-esteem/ability to intervene when they come across a person with suicidality in the field. Developing a suicide prevention training module for social work students would be a suitable measure for upbringing their skills in dealing with individuals with suicidality. Method: The purpose of the present study was to develop a suicide prevention training module for social work students at the postgraduate level. The researcher conducted two Focused Group Discussions (FGD) each with social work students (n = 13) and social work educators (n = 15) on an online platform. Notes were taken during the discussion, and the contents were videotaped. The videotaped content was transcribed, and content analysis was used to analyze the data. The content that emerged from the FGD with social work students and educators was discussed in later FGD with mental health experts (two psychiatrists, one psychologist, two psychiatric social workers, and two mental health nurses). The discussion with experts clarified what components to retain for the training program. Results: Five major themes and 22 sub-themes emerged from the two FGDs each with students and educators, and one FGD with mental health professionals are described. The five major themes were understanding of suicidality, understanding suicide education in the master of social work curriculum, experience with suicidality, training content suggestion, and suggestions for future implications. Conclusions: The present study identified the need for suicide prevention training in postgraduate-level social work students. Furthermore, a lack of suicide prevention training was observed indicating the incorporation of suicide education in the postgraduate curriculum.

Perceptions of key stakeholders on peer led strength building program for suicide prevention among young adolescents: A qualitative study from Karnataka, India.

Context: Adolescent suicides are a significant public health concern in India and understanding the intersecting perspectives becomes imperative for the prevention of various mental health concerns. Aim: Assessing perceptions of various key stakeholders, that is, mental health experts, school and college teachers, and District Mental Health Program staff about peer-led strength building programs for suicide prevention. Settings and Design: A cross-sectional qualitative design using two Focus Group Discussions (FGDs) with mental health experts and teachers and one FGD with DMHP staff was conducted. The sample comprised 45 participants from Bengaluru urban district. Materials and Methods: The data were analyzed manually by the method of direct content analysis, and themes were determined using existing literature. Results: The teachers and the DMHP highlighted the need for an intensive training program/module that is necessary to be developed in order to train the peer leaders first. The mental health experts opined that creating a network will help in easy identification of the cases and appropriate treatment could be provided without delays. Conclusions: This study indicated that suicide is a preventable public health emergency and inaccessibility to existing as well as proper support systems was perceived as a major concern. Therefore, peer-led programs are beneficial in steering and improving help seeking behavior in suicidal adolescents.

Reducing stigma and improving access to care for people with mental health conditions in the community: protocol for a multi-site feasibility intervention study (Indigo-Local).

Background: Stigma and discrimination towards people with mental health conditions by their communities are common worldwide. This can result in a range of negative outcomes for affected persons, including poor access to health care. However, evidence is still patchy from low- and middle-income countries (LMICs) on affordable, community-based interventions to reduce mental health-related stigma and to improve access to mental health care. Methods: This study aims to conduct a feasibility (proof-of-principle) pilot study that involves developing, implementing and evaluating a community-based, multi-component, public awareness-raising intervention (titled Indigo-Local), designed to reduce stigma and discrimination and to increase referrals of people with mental health conditions for assessment and treatment. It is being piloted in five LMICs - China, Ethiopia, India, Nepal and Tunisia - and includes several key components: a stakeholder group workshop; a stepped training programme (using a 'Training of Trainers' approach) of community health workers (or similar cadres of workers) and service users that includes repeated supervision and booster sessions; awareness-raising activities in the community; and a media campaign. Social contact and service user involvement are instrumental to all components. The intervention is being evaluated through a mixed-methods pre-post study design that involves quantitative assessment of stigma outcomes measuring knowledge, attitudes and (discriminatory) behaviour; quantitative evaluation of mental health service utilization rates (where feasible in sites); qualitative exploration of the potential effectiveness and impact of the Indigo-Local intervention; a process evaluation; implementation evaluation; and an evaluation of implementation costs. Discussion: The outcome of this study will be contextually adapted, evidence-based interventions to reduce mental health-related stigma in local communities in five LMICs to achieve improved access to healthcare. We will have replicable models of how to involve people with lived experience as an integral part of the intervention and will produce knowledge of how intervention content and implementation strategies vary across settings. The interventions and their delivery will be refined to be acceptable, feasible and ready for larger-scale implementation and evaluation. This study thereby has the potential to make an important contribution to the evidence base on what works to reduce mental health-related stigma and discrimination and improve access to health care.

Toward a multi-level strategy to reduce stigma in global mental health: overview protocol of the Indigo Partnership to develop and test interventions in low- and middle-income countries.

There is increasing attention to the impacts of stigma and discrimination related to mental health on quality of life and access to and quality of healthcare. Effective strategies for stigma reduction exist, but most evidence comes from high-income settings. Recent reviews of stigma research have identified gaps in the field, including limited cultural and contextual adaptation of interventions, a lack of contextual psychometric information on evaluation tools, and, most notably, a lack of multi-level strategies for stigma reduction. The Indigo Partnership research programme will address these knowledge gaps through a multi-country, multi-site collaboration for anti-stigma interventions in low- and middle-income countries (LMICs) (China, Ethiopia, India, Nepal, and Tunisia). The Indigo Partnership aims to: (1) carry out research to strengthen the understanding of mechanisms of stigma processes and reduce stigma and discrimination against people with mental health conditions in LMICs; and (2) establish a strong collaborative research consortium through the conduct of this programme. Specifically, the Indigo Partnership involves developing and pilot testing anti-stigma interventions at the community, primary care, and mental health specialist care levels, with a systematic approach to cultural and contextual adaptation across the sites. This work also involves transcultural translation and adaptation of stigma and discrimination measurement tools. The Indigo Partnership operates with the key principle of partnering with people with lived experience of mental health conditions for the development and implementation of the pilot interventions, as well as capacity building and cross-site learning to actively develop a more globally representative and equitable mental health research community. This work is envisioned to have a long-lasting impact, both in terms of the capacity building provided to participating institutions and researchers, and the foundation it provides for future research to extend the evidence base of what works to reduce and ultimately end stigma and discrimination in mental health.

Awareness and preferences about suicide crisis support service options among college students in India: A cross sectional study.

BACKGROUND: Our objective was to explore the awareness about suicide support services and preferred service options during a suicide crisis among college going young adults. METHODS: Between September 2016 and February 2017, we invited students from colleges affiliated to three major universities in a coastal district of South India to participate in a cross-sectional survey. RESULTS: A total of 1890 usable responses were obtained. Most participants (n = 1633, 86.4%) were unaware of any suicide crisis support options. Most commonly listed options were support from family members, peer groups, counselling and psychiatric consultation. These were also endorsed as most preferred support options. CONCLUSION: There is a low level of awareness about suicide support services among young Indian adults. There is a need for coordinated efforts to raise awareness and promote uptake of suicide support services in this group.

Determinants of family functioning in caregivers of persons with obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is known to cause significant burden to patients and their caregivers. However, there is limited data on its impact on family functioning, especially from families with an adult member having OCD. METHODS: Four hundred subjects, which included treatment-seeking adult OCD patients (n = 200) and their caregivers (n = 200) were recruited. Patients were evaluated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Caregivers were evaluated using the MINI, the Caregiver Strain Index (CSI), the Hamilton Anxiety Rating Scale (HAM-A), the Hamilton Depression Rating Scale (HAM-D), the Socio-Occupational Functioning Assessment Scale (SOFAS), the Family Accommodation Scale (FAS) and the Connor-David Resilience scale (CD-RISC) in a cross-sectional interview. Family functioning was measured using the OCD Family Functioning (OFF) Scale. Structural equation modeling (SEM) was carried out to evaluate the relationships between the patient and caregiver variables to predict family functioning. RESULTS: From the best-fitting path model, we ascertained that OCD symptoms did not have a direct relationship with family dysfunction. Their effects were in turn was mediated by family accommodation, anxiety, caregiver stress/burden and depression. "Contamination & washing" was the only significant symptom dimension within the model. Caregiver resilience was found to predict only their individual functioning, and not family functioning. LIMITATIONS: Study sample included patients from a tertiary care OCD service, only one caregiver from each patient's family was interviewed. CONCLUSIONS: Evaluating family functioning, addressing it as part of interventional modules for patients and caregivers may help improving treatment outcomes.

Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe.

BACKGROUND: Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction. METHODS: Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis. RESULTS: Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner. CONCLUSIONS: Primary care providers' willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.

Suicidal Ideation among Persons with Alcohol Use Disorder: A Cross-Sectional Study.

Background: Suicide is a major threat to public health worldwide. Evidence suggests alcohol use disorders (AUD) are associated with suicide ideation. There is a paucity of studies in India regarding suicidal ideation among individuals receiving in-patient treatment for alcohol dependence. Aim: To assess the suicidal ideation and its severity among persons with alcohol use disorder. Methods: Cross-sectional research design was used. Totally 47 persons with alcohol use disorder receiving in-patient treatment were screened for suicidal ideation using a consecutive sampling technique based on inclusion and exclusion criteria at centre for addiction medicine, tertiary care teaching hospital at Bangalore. An interview schedule was used to collect the data. Tools: Mini+ suicidality was used for screening suicidal ideation and Columbia suicide severity rating scale was used to assess the frequency and severity of the suicidal ideation. Descriptive statistics such as frequency, percentage, mean were used for data analysis. Results & Discussion: Out of 47 patients, 29 reported having suicidal ideations (62%). AUD suicidal ideation was more among persons belong to below poverty line, lower education level, unemployed, married, living with family of origin, nuclear family, urban, using tobacco. Their mean age was 35 years (±6.6). Majority (62%) of them had suicidal ideation in the past one month, 43% reported having thought to kill themselves over the past one month. One-third (35%) able to control suicidal thought with lot of difficulty, 83% reported that deterrents stopped them attempting suicide, 82%wanted to end their life to end or stop the pain that they are enduring. Conclusion: The prevalence of suicidal ideations is high among persons with alcohol use disorder. Socio-demographic factors likely to have an influence on suicidal ideation among persons with alcohol use disorder.

Crossing barriers: Role of a tele-outreach program addressing psychosocial needs in the midst of COVID-19 pandemic.

Novel Coronavirus disease 19 (COVID 19) pandemic has affected more than 2 million individuals and causing over 0.1 million deaths worldwide. In India, the pandemic has gained momentum in the last few weeks with over 10,000 cases and 400 deaths. In the absence of any pharmacological cure on the horizon, countries have resorted to the use of strict public health measures to curtail spread of further infection to fight the coronavirus. The pandemic and its social implications have triggered mental health concerns among the masses. Providing psychological first aid and psychosocial support is vital in mitigating the distress and enhance the coping strategies of people to deal with this biological disaster. Tele-mental health services play an important role in this regard. In this article we describe our preliminary experience in understanding the psychological concerns of general public and addressing them by providing psychological support through a national telephonic helpline.

"It's a battle for eyeballs and suicide is clickbait": The media experience of suicide reporting in India.

INTRODUCTION: Suicide rates in India are among the highest in the world, equating to over 200,000 suicide deaths annually. Crime reports of suicide incidents routinely feature in the Indian mass media, with minimal coverage of suicide as a broader public health issue. To supplement our recently published content analysis study, we undertook qualitative interviews to examine media professionals' perspectives and experiences in relation to media reporting of suicide-related news in India. MATERIALS AND METHODS: In 2017-18, semi-structured qualitative interviews with twenty-eight print media and television media professionals with experience reporting on suicide-related news were undertaken across north (New Delhi and Chandigarh) and south (Chennai) India. A semi-structured interview guide was designed to initiate discussions around; 1) perspectives on why suicide incidents are regularly reported on by mass media in India, 2) a description of experiences and processes of covering suicide incidents on the crime beat; and 3) perspectives on the emergence of health reporter coverage of suicide. Interviews were digitally audio-recorded and transcribed. A deductive and inductive thematic analytic approach was used, supported by the use of NVivo. RESULTS: Suicides were typically seen as being highly newsworthy and of interest to the audience, particularly the suicides of high-status people and those who somewhat matched the middle-class profile of the core audience. Socio-cultural factors played a major role in determining the newsworthiness of a particular incident. The capacity to link a suicide incident to compelling social narratives, potentially detrimental social/policy issues, and placing the suicide as a form of protest/martyrdom increased newsworthiness. Reporters on the crime beat worked in close partnership with police to produce routine and simplified incident report-style coverage of suicide incidents, with the process influenced by: informal police contacts supporting the crime beat, the speed of breaking news, extremely tight word limits and a deeply fraught engagement with bereaved family members. It was articulated that a public health and/or mental health framing of suicide was an emerging perspective, which sought to focus more on broader trends and suicide prevention programs rather than individual incidents. Important challenges were identified around the complexity of adopting a mental health framing of suicide, given the perceived pervasive influence of socioeconomic and cultural issues (rather than individual psychopathology) on suicide in India. CONCLUSIONS: Our findings delve into the complexity of reporting on suicide in India and can be used to support constructive partnerships between media professionals and suicide prevention experts in India. Policymakers need to acknowledge the socio-cultural context of suicide reporting in India when adapting international guidelines for the Indian media.

Predictors of family accommodation in obsessive compulsive disorder.

Family accommodation (FA) has been consistently recognized as a predictor of treatment outcome in obsessive-compulsive disorder (OCD). However, the factors determining FA are not clearly understood, especially in adult patients with OCD. We recruited a consecutive sample of predominantly adult subjects (n=100), who presented to the specialty OCD Clinic with a primary diagnosis of OCD along with a suitable caregiver. Patient and family members completed measurements assessing FA along with other clinical variables of interest. Clinical variables found statistically significant in bivariate analyses (p < 0.05) were examined in multivariate linear regression analysis to determine the predictors of FA. Age, gender and marital status of the patient, contamination symptom dimension, severity of avoidance, severity scores on Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and scores on work and social adjustment scale were associated with FA in bivariate analysis. In multiple regression analysis, contamination dimension, the severity of avoidance, relationship of caregiver and poorer work and social adjustment predicted FA. Patients with poor socio-occupational functioning, severe avoidance, caregiver being spouse and contamination related symptoms are accommodated more by family members. Screening and management of FA, particularly in patients with the contamination dimension may thus help improve treatment outcome.

Long-term Outcomes of Intensive Inpatient Care for Severe, Resistant Obsessive-Compulsive Disorder: Résultats à long terme de soins intensifs à des patients hospitalisés pour un trouble obsessionnel-compulsif grave et résistant.

OBJECTIVE: A substantial proportion of severely ill patients with obsessive-compulsive disorder (OCD) do not respond to serotonin reuptake inhibitors (SRIs) and are unable to practice cognitive behavioral therapy (CBT) on an out-patient basis. We report the short-term (at discharge) and long-term (up to 2 years) outcome of a multimodal inpatient treatment program that included therapist-assisted intensive CBT with adjunctive pharmacotherapy for severely ill OCD patients who are often resistant to SRIs and are either unresponsive or unable to practice outpatient CBT. METHODS: A total of 420 patients, admitted between January 2012 and December 2017 were eligible for the analysis. They were evaluated using the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive Compulsive Scale (YBOCS), and the Clinical Global Impression (CGI) scale. All patients received 4 to 5 therapist-assisted CBT sessions per week along with standard pharmacotherapy. Naturalistic follow-up information at 3, 6, 12, and 24 months were recorded. RESULTS: At baseline, patients were mostly severely ill (YBOCS = 29.9 ± 4.5) and nonresponsive to ≥2 SRIs (83%). Mean duration of inpatient stay was 42.7 ± 25.3 days. At discharge, there was a significant decline in the mean YBOCS score (29.9 ± 4.5 vs. 18.1 ± 7.7, P < .001, Cohen's d = 1.64); 211/420 (50%) were responders (≥35% YBOCS reduction and CGI-I≤2) and an additional 86/420 (21%) were partial responders (25% to 35% YBOCS reduction and CGI-I≤3). Using latent class growth modeling of the follow-up data, 4 distinct classes were identified, which include "remitters" (14.5%), "responders" (36.5%), "minimal responders" (34.7%), and "nonresponders" (14.6%). Shorter duration of illness, better insight, and lesser contamination/washing symptoms predicted better response in both short- and long-term follow-up. CONCLUSION: Intensive, inpatient-based care for OCD may be an effective option for patients with severe OCD and should be considered routinely in those who do not respond with outpatient treatment.