COMMENTARY: The Consumer Protection Act, 2019: A critical analysis from a medical practitioner's perspective.

The landmark judgment in the case of Indian Medical Association v VP Shantha in 1995 brought the medical profession under the ambit of the Consumer Protection Act, 1986. The Consumer Protection Act, 1986, was later repealed and replaced by the Consumer Protection Act, 2019. This article delves into the implications of the 2019 Act, highlighting significant changes in its scope, including the expansion of the definition of "consumer" and the incorporation of telemarketing and e-commerce within its ambit. Moreover, the amendments affect pecuniary jurisdiction, grounds for litigation, and introduce mediation cells, and the Central Consumer Protection Authority (CCPA). This article underscores concerns related to an increase in frivolous cases against medical practitioners and in defensive practice, ultimately impacting the overall quality of patient care. Recommendations for timely redressal and safeguards against unwarranted litigation are proposed to mitigate the adverse implications of the amended Act and ensure the well-being of both healthcare providers and patients.

Exploring the early history of convulsive therapies at the Mysore Government Mental Hospital (currently NIMHANS).

OBJECTIVE: The paper describes the introduction, and early use of chemically and electrically induced convulsive therapies, at the Mysore Government Mental Hospital (MGMH), now the National Institute of Mental Health and Neuro Sciences, Bangalore, India. Cardiazol and ammonium chloride were used at MGMH before the introduction of electroconvulsive therapy (ECT). The study examines the early history, clinical correlates and outcome of convulsive therapies and attempts to contextualize how local conditions influenced implementation. METHOD: Three sets of archival case-records from 1938 to 1948, each of a period of 9 months following the implementation of a particular mode of convulsive therapy were reviewed. RESULTS: During the examined timeframe, 40 patients received cardiazol, 95 ammonium chloride and 50 unmodified ECT. Schizophrenia was the commonest clinical indication for convulsive therapy across all modalities of treatment. When outcomes were examined, 45%, 48.4% and 62% of patients were clinically reported to have been either cured/improved after receiving cardiazol, ammonium chloride and ECT respectively. Those receiving cardiazol had a high mortality of 22.5%, compared to 3.1% for ammonium chloride and 4% with ECT. CONCLUSIONS: Convulsive therapies were one of the first somatic psychiatric treatments, introduced around 1930s and 1940s all over the world, including in India. Our archival records suggest that many international ideas about somatic treatments were quickly adopted in India. Electroconvulsive therapy and other novel neuromodulatory interventions continue to be used and actively researched in India.

Cutoff for Benchmark Disability Using World Health Organization Disability Assessment Schedule 2.0: A Community-Based Cross-Sectional Study from Rural South India.

Background: India uses the Indian Disability Evaluation and Assessment Scale (IDEAS) for quantifying disability due to mental illness. The cutoff score for benchmark disability is 7. India has adopted International Classification of Functioning and Health (ICF) and thereby is a signatory to use World Health Organization Disability Assessment Schedule (WHODAS). Cutoff for benchmark disability in WHODAS in a community-based sample is lacking. Methods: The study was conducted in Jagaluru Taluk, Davanagere District, Karnataka. It is a part of an ongoing research funded by Indian Council of Medical Research. Frequency, percentages, mean, standard deviations, mode, median, Receiver Operating Characteristic Curve were used in analyzing the data. Results: The study included 184 persons with severe mental illness with mean age of 47 and average duration of illness (DOI) of 11 years. They had mild disability (5.99) in IDEAS. The corresponding cutoff score in WHODAS, as compared to IDEAS, when the influence of DOI is removed was 24. Conclusions: A shift from IDEAS to WHODAS is feasible. With the undue influence of DOI removed, both hospital and community-based samples show the score of 24 as cutoff.

An audit of initial six years of 5885 telepsychiatric direct video consultations: Findings from "benefits of savings" analysis and the effect of COVID-19 pandemic.

Background: Telepsychiatric direct video consultations (DVCs) meant for continuity of care began in 2017 and continued during the coronavirus disease 2019 (COVID-19) pandemic. Telemedicine-based consultation gained its long-due importance during the COVID-19 travel restriction, despite its existence for a long. The authors intend to share the utility and growth of the initial six years of live telepsychiatric DVCs from an academic hospital in India and also plan to understand the effects of the COVID-19 pandemic on its growth and report findings from an innovative "benefits of savings" (BOS) analysis from these clinics. Methods: A first six years of medical audit of the files and registers of telepsychiatric DVCs from two kinds of continuity of care clinics during 2017-2022 is performed. An analysis of 4991 (84.8%) live DVCs is successfully conducted for 1570 patients from the 5885 scheduled appointments. Year-on-year (YOY) growth and BOS analysis of successful DVCs from these clinics were performed. Results and Discussion: The growth suggests a gradual increase in DVCs yearly. The BOS analysis suggests its increased acceptability, feasibility at both user and provider ends, and possible cost-effectiveness of these video clinics. YOY analysis suggests a natural growth of these clinics than from the effect of the COVID-19 pandemic, except for an initial surge in 2020 and 2021 and observing stabilization effect by 2022. Conclusion: In the authors' understanding, this is the largest study of providing DVCs from India, irrespective of any medical/surgical specialty. The video/remote clinics could be an alternative model for regular follow-ups in ensuring the continuity of care among patients with psychiatric disorders. These clinics also saved significant travel time, travel distance, and travel costs for the patients that could have occurred for their in-person consultations.

Impact of incentivizing ASHAs on the outcome of persons with severe mental illness in a rural South Indian community amidst the COVID-19 pandemic.

BACKGROUND & OBJECTIVES: Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs). We examined the impact of incentivizing ASHAs on the outcome of persons with severe mental illness (SMI) amidst the pandemic. METHODS: One hundred eighty-four adults with SMI from Jagaluru taluk were enrolled and followed up for a year. They were assessed for disability, work performance, internalized stigma, and illness severity at baseline, six months, and 12 months follow-up. ASHA workers were incentivized to ensure follow-up consultations, address concerns regarding illness/ medication side effects and monitor medication adherence. RESULTS: Out of the 184 recruited patients, 7 died (non-COVID-19 causes), 22 stopped treatment and did not report for follow-up consultations, 11 shifted to treatment from other centers, and in 1 case, there was a change in diagnosis. 143 (78%) patients with SMI completed the study amidst the COVID-19 pandemic. At one year follow-up, there was a significant reduction in disability, illness severity, self-stigma, and improved work performance. CONCLUSION: Incentivization of ASHAs helped ensure continuity of care to persons with SMI despite lockdowns and COVID-19 exigencies. It is feasible to involve ASHAs in the treatment of persons with SMI.

The Initial Epoch of Psychosurgery in India: A Retrospective Data Review from Mysore Government Mental Hospital.

Background: In the early 20th century, psychosurgery had gained worldwide popularity for treating mentally ill persons, especially in western countries. We attempt to chronicle its journey in the Mysore Government Mental Hospital (MGMH), now the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. Methods: Archived case records and registers of patients admitted from 1939 to 1947 were reviewed to identify those who had undergone psychosurgery. Case records of the identified patients were assessed for clinical information, including the details of psychosurgery. Results: Among the patients, 107 had undergone psychosurgery, primarily leucotomy. Schizophrenia (51.5%) was the most common diagnosis in them, and 33.7% of all patients were reported to have improved. Yet, inconsistencies were found about the presence and degree of improvement. Possible side effects were not consistently documented. Conclusion: Psychosurgery was adopted at the MGMH very soon following its introduction in the western world. However, ambiguity about its benefits and risks was noted in the current study.

Marriage in persons with severe mental illness: A narrative review-based framework for a supported relationship.

Background: Studies in the past have shown the effect of mental illness on marriage in persons with severe mental illnesses (SMIs). Primary care and family physicians have a major role in addressing marriage-associated dilemmas in their life. Methods: The literature search was conducted from databases such as PubMed, ProQuest, EBSCO, Scopus, and Google Scholar for understanding the context and the problem in-depth for bringing out the narrative-review based framework for addressing the dilemmas. Results: Marriage rates in persons with SMI are high in Eastern countries. Marriage in persons with SMI enhances social support and prevents the stigma of being unmarried. Disability, unemployment, stigma, and disclosure-related issues are barriers to getting desirable alliances. Evidence based interventions are available to reduce the associated distress to an extent. Conclusion: Published peer-reviewed literature has pointed out that marriage plays a significant role in the life of persons with SMI and their families, especially in Asian countries where marriage is an important social institution. It can have a positive impact or can lead to relapse, marital conflicts, and divorce based on contextual and clinical factors. Hence, there is a need to come up with tailor-made interventions to address marriage-related expectations in persons with SMI.

Schizophrenia spectrum disorders in India: A population-based study.

Introduction: Schizophrenia spectrum disorders represent a significant global health concern, contributing significantly to the global burden of disease. The National Mental Health Survey (NMHS) of India, conducted between 2015 and 2016, investigated the prevalence and epidemiological correlates of schizophrenia spectrum disorders in India. Materials and Methods: The NMHS conducted a population-based cross-sectional study in 12 Indian states from 2015 to 2016, encompassing 34,802 adults. The overall study design of the NMHS was a multistage, stratified, random cluster sampling technique, incorporating random selection based on probability proportion to size at each stage. The Mini-International Neuropsychiatric Interview 6.0 was used for psychiatric diagnoses, disability was assessed using Sheehan's disability scale, and the illness-related socioeconomic impact was assessed using a questionnaire based on the World Health Organization Disability Assessment Schedule 2.0. Firth penalized logistic regression was employed to understand the correlates of current schizophrenia spectrum disorder. Results: The study found a lifetime prevalence of schizophrenia spectrum disorders at 1.41%, with a current prevalence of 0.42%. A substantial treatment gap of 72% existed for current cases, rising to 83.3% in urban non-metro areas. The penalized logistic regression revealed that the age group category of 30-49 years, unemployed status, and lower education level had higher odds of association with schizophrenia spectrum disorders. Conclusion: The primary finding of this study is a lifetime prevalence of 1.41%, a current prevalence of 0.42%, and a substantial treatment gap of 72%. Addressing this treatment gap and holistic intervention is crucial for reducing the socioeconomic impact of this disorder. Strengthening the National Mental Health Program and implementing community-based rehabilitation are essential first steps in this direction.

Profiles of Victimized Outpatients with Severe Mental Illness in India.

Persons with severe mental illness (PwSMI) are at risk of being victimized due to persistent cognitive, emotional, and behavioral symptoms, which can become potential threats for effective reintegration into the community. A total of 217 PwSMI, receiving outpatient psychiatric treatment from a tertiary hospital, were screened for abuse, and if they were identified as abuse, then information about contextual factors contributing to abuse, sociodemographic, family, and clinical and legal profiles was created. Overall, 150 PwSMI were victimized, of which 56% were females, 50.7% were married, 20.7% were educated up to middle school, and 31.4% were homemaker. The most common form of diagnosis was schizophrenia (43.3%), with a mean duration of illness of 14 years. All the victimized PwSMI were subjected to emotional abuse. PwSMI were more likely to be victimized by multiple family members due to poor knowledge and understanding about illness (24%). The majority of the PwSMI had disclosed abuse (62.7%) to nonformal sources (33.3%) with no documentation in the clinical file (82.7%). PwSMI experience ongoing abuse and are more likely to be re-victimized, which increases the need for regular screening and culturally sensitive and comprehensive community-coordinated care and support.

Current telepsychiatry practice in India - An online survey of psychiatrists.

Context: Telemedicine Practice Guidelines and Telepsychiatry Operational Guidelines released in 2020 have provided legal backing for telepsychiatry practice. Aims: To understand the current telepsychiatry practices in India. Settings and Design: An online survey was conducted after ethics approval by the IPS Ethics Review Board. All psychiatrists, who are members of the Indian Psychiatric Society and whose email address was available with the society, were sent the survey link by email. Methods and Material: Information about existing telepsychiatry consultation practices in India was collected between June and July 2020. Statistical Analysis Used: Frequency, percentages, mean, and standard deviation were calculated. Results: 340 responses were analyzed. Nearly three-fourths of the responders used smartphones (n = 260, 76.47%) for audio consultations (n = 196, 57.65%). Among those who were using a dedicated software (n = 36), one-third used the Zoom software (n = 12, 33.33%). Nearly three-fourths (n = 218, 73.4%) provided prescriptions with their registration number on a letterhead in the form of an email or text message. Two-thirds of the responders (n = 228, 67.06%) felt that in-person consultation is better. Many preferred a combination of voice, video, and text including emails (n = 134, 42.01%). Conclusions: This online survey showed that the use of technology has caught up with the practicing psychiatrists. Many are practicing telepsychiatry either formally or informally in India and are comfortable and satisfied with the telepractice.

The prescriptions of psychotropic medications in telepsychiatry: An online survey of psychiatrists in India.

Context: Over the years, telepsychiatry services have expanded in many institutes. The Telemedicine Practice Guidelines and Telepsychiatry Operational Guidelines (TPOG) released in 2020 have been received by the fraternity with a mixture of apprehension, relief, and dissatisfaction on the list of drugs provided in Lists O, A, B, and C. Many psychiatrists have raised the issues of having a consensus in the formulation of List A. Aims: To draw consensus on the medications that can be listed in Lists O, A, B, and C in TPOG-2020. Settings and Design: This was an online survey with ethics approval by the Indian Psychiatric Society Ethics Review Board. All psychiatrists, who are members of the Indian Psychiatric Society and whose E-mail address was available with the society, were sent the survey link by E-mail. Methodology: Opinions and suggestions on Lists O, A, B, and C of TPOG-2020 and reasons for the suggestions were collected. Statistical Analysis Used: Frequency, percentages, mean, and standard deviation were calculated. T-test and Chi-square tests were used to see the influence of demographics on the concurrence of the lists. Results: Responses from 340 responders were analyzed. Majority of the responders agreed that List O (277, 85.5%), List B (263, 82.4%), and List C (223, 69%) are apt except for List A (162, 50.3%). Conclusions: This online survey showed that majority of the responders agreed to the lists except for List A. The approach taken to include the medications in List A, which was to include the essential drugs, has various benefits. However, the lists are not final, and the results of this survey may become an impetus to modify the list in the next edition of TPOG.

Perceived advantages and disadvantages of telepsychiatry - An online survey of psychiatrists in India.

Context: Telepsychiatry is being practiced in India for many years but was formalized only in 2020. It has many advantages and disadvantages. Aims: This study aimed to understand the perceived advantages and disadvantages of telepsychiatry practices in India. Settings and Design: An online survey with ethics approval by the Indian Psychiatric Society (IPS) Ethics Review Board. All psychiatrists who are members of the IPS and whose email address was available with the society were sent the survey link by email. Methodology: Information about existing telepsychiatry consultation practices in India and perception of advantages and disadvantages by the practitioners were collected between June and July 2020. Statistical Analysis: Frequency, percentages, mean, and standard deviation were calculated. Results: Responses by 340 responders were analyzed. Majority of the responders felt that telepsychiatry would provide easy accessibility to mental health services (n = 283, 83.24%) and would lead to less exposure to infections (n = 222, 65.29%). Half of the responders (n = 177, 52.06%) felt that there would be an increased doctor shopping resulting in poor care and nearly three-fourth (n = 245, 72.06%) felt that mental health professionals would fall into a problem while dealing with a suicidal or a homicidal patient. Some expressed that the inability to do physical and central nervous system examinations could lead to missing out comorbidities. About one-third (n = 117, 36.56%) felt that the patient recording the consultation would be a legal issue. Conclusions: This online survey showed that psychiatrists perceive many advantages and some disadvantages in practicing telepsychiatry.

Continuity of Care for Persons With Serious Mental Illness in a Rural Rehabilitation Program During the COVID-19 Pandemic in India.

The COVID-19 pandemic has posed challenges to community-based rehabilitation (CBR) for persons with mental illness, especially in resource-constrained settings. This column discusses the pandemic-related challenges faced by a rural CBR program in Jagaluru taluk (a subdistrict) in Karnataka, India. Thanks to stakeholder collaboration, task shifting with lay health workers, and implementation of telepsychiatry, the authors' clinical team could ensure uninterrupted medical care for persons with serious mental illness. Other CBR components were reduced because of pandemic-imposed resource and logistic constraints.

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.

Free legal aid for persons with mental illness and other marginalized group of population.

The marginalized and vulnerable population like those with mental illnesses and other disabilities, senior citizens, disaster victims and women are at risk of facing violation of their rights. To preserve the rights of the above-mentioned vulnerable groups, Government of India has passed a legislation named Legal Services Authority Act, 1987. In this article authors discuss the interconnection between mental illness and rights violation, how Legal Services Authority Act, 1987 is relevant in preserving rights of persons with mental illness and other vulnerable groups, different programs under the above legislation, the provisions under those programs and how to obtain them.

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.

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.

Telemedicine Practice Guidelines and Telepsychiatry Operational Guidelines, India-A Commentary.

Recent advancements in technology, access to smartphone, and gains achieved in increased internet speed and data transfer have expanded the scope of health care service delivery through the digital platforms. In India, telemedicine services remain poorly adopted and integrated due to various barriers. The important reasons are lack of legal and administrative clarity in using technology for service delivery and inertia from health service providers to adopt newer developments. However, during coronavirus disease (COVID-19) pandemic, these equations are changing. The Telemedicine practice guidelines released in March, 2020, and Telepsychiatry operational guidelines released in May, 2020, appear to remove these barriers and promote equitable access to health care. In this article, the authors discuss the scope of these guidelines.