Effectiveness of blended versus fully digital training in primary care psychiatry: A retrospective comparison from India.

Objectives: We compared effectiveness of blended mode (consisting of traditional classroom teaching and e-learning sessions) and fully digital mode (e-learning sessions alone) of primary care psychiatry training for primary care doctors in Chhattisgarh. Materials and Methods: We retrospectively compared the engagement in training, knowledge (K), attitude (A), and practice (P) in primary care psychiatry, and patient identification by primary care doctors (n = 941) from Chhattisgarh region who underwent training through either blended training mode (n = 546) or fully digital training mode (n = 395) for 16 h each, using Clinical Schedules for Primary Care Psychiatry based modules between June 2019 and November 2020 with a tertiary care center (NIMHANS, Bengaluru) as hub. Statistical Analysis: The Statistical Package for the Social Sciences version 27 was used to analyze the data. Continuous variables were analyzed using the independent samples t-test, and discrete variables were analyzed using the Chi-square test. A repeated measures analysis of variance (ANOVA) (two-way mixed design) was used to see the interaction of training type and time of pre- and post-KAP measurement while controlling for years of experience. The number of patients identified by both training groups over 8 months was also compared using the repeated measures ANOVA (two-way mixed design). Results: Engagement inferred by the number of participants completing pre-KAP forms (75%), post-KAP forms (43%), post-session assessments (37- 47%), case presentation (33.9%), and certification (32.1%) was better in the blended group (P < 0.05). The mean gain in KAP scores was significantly higher in the blended group controlling for the years of experience as primary care doctor (PCD) (F = 30.36, P < 0.001). PCDs in the blended training group consistently identified a higher number of patients with mental illness over 8 months of follow-up (F = 6.21, P < 0.001). Conclusion: The blended mode yielded better results in primary care psychiatry training compared to fully digital mode. In-person interactions while provided for a very brief proportion of the training seem to have an unmistakable imprint on the outcomes and seem critical for better consolidation and assimilation of information, which translates into better practice.

Stake holder perspectives on the role of accredited social health activists (ASHAs) in Indian public mental healthcare space: A qualitative study.

Background: Community health workers such as Accredited Social Health Activists (ASHAs) are existing resources who can facilitate the bridging of the mental health treatment gap. Knowing about the perspectives of ASHAs in delivering mental health care and other professionals with experience working in the area of community mental health is imperative. Method: As part of an implementation research project aimed at comparing the effectiveness of two training methods for community health workers (ASHAs), we conducted five focussed group discussions including four with ASHAs (n = 34) and one with other stakeholders (n = 10). Focussed Group Discussion (FGD) was conducted under the following themes: acceptance and feasibility of provision of mental health services from ASHA's point of view and understanding the supply and demand side opportunities and challenges. The discussion began with open-ended questions, allowing for new themes to emerge until saturation was reached. Results: ASHAs were willing to incorporate mental health identification (and referral) in their regular activities without additional perceived burden. ASHAs were easily able to identify severe mental disorders (SMDs). For substance use disorders (SUDs), due to factors such as normalization of substance consumption and stigma, there was a felt difficulty in the recognition by ASHAs. ASHAs' difficulty in identifying the CMDs was because of poor awareness in both those with mental illness and ASHAs. Incentivizing the work of ASHAs was thought to yield more returns. Conclusions: ASHAs have the potential to be excellent resources for easy screening, identification, and follow-up of those with mental health concerns in the community. Policies to involve them need to evolve.

Chhattisgarh community mental healthcare tele-mentoring program (CHaMP): Digitally driven initiative to reach the unreached.

OBJECTIVE: Harnessing technology is one accepted method to leapfrog the barrier of inadequate trained human resources for mental health. The Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP) is a collaborative digitally driven initiative of the Government of Chhattisgarh (GOC) and the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru the aim of which is to train the Primary Care Doctors (PCDs) and Rural Medical Assistants (RMA) to identify, screen and treat/refer cases of mental health disorders presenting to the primary care settings (n = 2150). The objective of this article is to give a brief overview of the initiative. METHODS: CHaMP consists of the following modules: (a) a brief on-site training (b) eLearning and Skill Development (eLSD) and (c) Collaborative Video Consultation (CVC). The latter two are andragogic training methods delivered digitally. RESULTS AND CONCLUSION: From August 2019 to May 2020, 501 PCDs and RMAs have been covered. During this time, they have cared 15,000 patients suffering from mental illness, which hitherto was not the case. Technology that is easily available and usable has the potential to overcome the big hurdle of inadequate mental health human resources in India.

Criminal Responsibility in Geropsychiatry: Competence, Culpability, and Care.

Elderly persons can get involved in the criminal justice system as victims or as perpetrators. The interaction of elderly persons with mental illness at various cross-sections of the judicial process needs thoughtful consideration. Through this review, the authors approach this less studied aspect of forensic psychiatry. Concerning the evaluation of a prisoner, three scenarios need focused consideration: evaluation for fitness to stand trial before a competent court, evaluations for an insanity defense, and fitness for sentencing. At the same time, incarcerated elderly who developed dementia or a severe mental illness at any point of time during the trial or in prison need specific approaches. In this article, the authors discuss the acts and case laws relevant to navigating these legal scenarios. We discuss existing mental health care provisions for protecting the health interests of elderly care in prison.

Future-Proofing Geriatric Mental Health Care Services in India: Training and Policy Directions.

BACKGROUND: A burgeoning rise in the elderly subpopulation is being noted in India. This rise has already earned the designation as a shining nation by the United Nations/World Health Organization. This growth will take the elderly subpopulation to 324 million persons above 60 years by 2050. The mental health needs of this subpopulation are varied and nuanced compared to that of the general population. The risk and prevalence of mental health morbidity are also greater. There is an urgent need to gear up the health care systems. CONSIDERATIONS: Various aspects of the ongoing demographic transitions are considered alongside available health information. Legislative mandates and laws are also reviewed to provide context to qualify the action points and recommendations. Recommendations, India must act urgently to strengthen health care delivery systems in a concurrent multipronged approach. These efforts should focus on developing trained Human Resources and adequate infrastructural resources. Review mechanisms to inform on required updates on best practices and evidence-based medicine must also be incorporated and developed to perform periodically.

Impact Evaluation of Technology Driven Mental Health Capacity Building in Bihar, India.

Task-shifting is an important means to address the barrier of inadequate specialist human resources for mental health in countries such as India. This paper aims to report the impact of one such task-shifting initiative. Twenty-two non-specialist Medical Officers of Bihar, an eastern Indian state were engaged in a ten-month long hybrid (a 15-days onsite orientation to psychiatry and periodic online mentoring in primary care psychiatry) training program to enable them to identify commonly presenting psychiatric disorders in their respective clinics. 20 online sessions (hub and spoke ECHO model) occurred over the next 10 months. Apart from didactic topics, 75 cases covering severe mental disorders, common mental disorders and substance use disorders were discussed (case presentations by the primary care doctors (PCDs)) and moderated by a specialist psychiatrist and clinical psychologist). 12 successive self-reported monthly reports (comprising of the number and nature of psychiatric cases seen by the trainee PCDs) were analyzed. The mean (SD) number of sessions attended was 9 (8.0) and median was 13 (Range: 0-20). Mean number of cases (per PCD) discussed was 3.4 (3.4) (Median: 4; Range: 0-10). Total 20,909 patients were cared for in the 12 months after initiation of the training program. Increasingly, a greater number of patients were cared for as the training progressed. This pattern was mainly driven by more identifications of severe mental disorders (SMDs), common mental disorders (CMDs), dementias and substance use disorders. Mean (SD) number of patients seen per month before and after training was 1340.33 (86.73) and 1876.44 (236.51) (t = - 3.5, p < 0.05) respectively. A hybrid model of training PCDs is feasible and can be effective in identification of persons with psychiatric disorders in the community. Prospective, well designed studies are essential to demonstrate the effectiveness of this model.

Consent in current psychiatric practice and research: An Indian perspective.

Consent is a process that allows for free expression of an informed choice, by a competent individual. The consent is considered as one of the important components of health-care delivery and biomedical research today. Informed consent involves clinical, ethical, and legal dimensions and is believed to uphold an individual's autonomy and the right to choose. It is very important in Indian mental health care as the Mental Healthcare Act (MHCA) 2017 mandates informed consent in admission, treatment, discharge planning, and research intervention/procedures. In 2017, the Indian Council of Medical Research laid down the National Ethical Guidelines for BioMedical and Health Research involving Human Participant for research protocols, which the MHCA advocates. This article gives an overview on the evaluation of consent in clinical practice and also highlights the approach and challenge in psychiatric practice in India.

Discharge planning and Mental Healthcare Act 2017.

Mental Healthcare Act 2017 mandates that proper discharge planning should be done and documented before any discharge is done from MHEs. Discharge planning should be based on a thorough assessment of the needs of the patient. Family should be actively involved in the planning process. Necessary steps should be taken for referral to other services, especially those in the community. Discharge planning helps us to balance the goals of the treatment at admission, to reality check at the time of discharge. Adequacy of discharge planning can be ensured by using various published checklists.

Newer documentary practices as per Mental Healthcare Act 2017.

Medical records form an integral part of patient care. Proper documentation and its maintenance are mandatory as part of the law. It is essential for a treating doctor to document the required details to avoid allegations of negligence. Proper documentation will not only help us to prove that particular services were provided but can also serve as a tool for communication with other professionals. This article draws together the standards and suggests some good clinical practices as per the Mental Healthcare Act 2017.