Clinical Profile, Course and Outcomes of Male Inpatients with Mental Illness Charged with Homicide: A Chart Review from an Indian Tertiary Care Hospital.

Background: The relationship between imprisonment and mental illness is bidirectional. The clinical outcomes of prisoners with mental illness have not been widely studied, especially in developing countries. This study was conducted to assess the same among male inpatients under judicial custody with charges of homicide. Methods: A retrospective chart review of male forensic ward inpatients admitted between January 1, 2003, and December 31, 2016, was conducted. Diagnosis in the files was based on the International Classification of Diseases (ICD)-10 criteria. The Clinical and Global Improvement-Severity (CGI-S) scale was used to measure the severity of illness. Mean CGI-S assessment was carried out at baseline, end of 1 year, 5 years, and 15 years. The data were analyzed using descriptive statistics, Friedman's test, and Dunn's post hoc test. Results: Schizophrenia spectrum disorders and other psychotic disorders, mood disorders, and alcohol use disorders were diagnosed in 62(49.6%), 22(17.6%), and 44(35.2%) subjects, respectively. Forty-one (32.8%) subjects had at least one readmission. The average CGI-S score for the total subjects was 5 (markedly ill) at baseline and 2 (borderline ill) at the end of their latest contact with the tertiary care hospital. For the 34 subjects (27.2%) who had follow-up information of 15 years, the average CGI-S score was 1 (normal, not at all ill) at the end of 15 years (P < 0.001). Conclusion: Clinical outcomes of prisoners with mental illness seem promising, subject to the seamless availability of services. Studies from other parts of the country are required for a more systematic understanding of the requirements of care.

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.

A camp approach of community psychiatry in India: Past, present, and the future.

Camps are a popular approach to deliver medical care in India. While it is usually a one-off event for physical ailments, it is a long-term affair in Psychiatry. One of the first camps in psychiatry was rolled out as early as in 1967 at Mandar, Ranchi, followed by Raipur Rani (Haryana) in 1976 and at Gunjur, Karnataka in 1977. This camp approach became extremely popular and got expanded across India as they were thought to be synonymous with community-based outreach for mental illnesses. In the past 5 years, however, newer models of community care have emerged, necessitating a relook at this traditional approach. In this paper, the authors trace the origin, utility and future directions of these camps, taking data from community psychiatry camps conducted by the National Institute of Mental Health and Neurosciences, Bengaluru, a premier neuropsychiatric tertiary care institute in India. Data have been collated from the annual reports of the Institute, database from the District Mental health Program, Government of Karnataka, India, and compared with published literature on the same field. While camps remain as one of the important avenues to reach the unreached, there is a need to change the approach of their functioning by incorporating training (primary care providers) aspects and collaborative care. The latter may make the initiative more meaningful and sustainable.

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.

Karnataka telemedicine mentoring and monitoring program for complete integration of psychiatry in the general health care.

The National Mental Health Survey of India reported a higher prevalence and treatment gap of psychiatric disorders among the general population. Task shifting is one of the important solutions to meet this requirement. The prevalence of psychiatric disorders among primary care is about 30%-50%. Digitally driven primary care psychiatry program (PCPP) designed to innovate different module to upscale the skills of primary care doctors (PCDs) in live consultation of PCDs in their general patients. To exponential coverage of PCDs, Karnataka Telemedicine Mentoring and Monitoring (KTM) Program is been implemented across all districts of Karnataka. It is the training of trainer version of PCPP where psychiatrists serving in District Mental Health Program of all districts of Karnataka become trainers to implement of two digital modules (Telepsychiatric On-Consultation Training and Collaborative Video Consultations) of PCPP with the target to train all PCDs of Karnataka. This paper aims to provide a glimpse of this innovative KTM program and current progress with a preliminary analysis of translational quotient indicating skill transfer and retention.

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.

Implementing National Mental Health Program: Local leaders' perspectives and lessons for national action.

The article is about a set of leadership programs on 'mental health leadership under NMHP' that was completed for 161 participants who are the district level health authorities and service providers (psychiatrists, psychologists, nurses and social workers) by the Community Psychiatry Unit of the Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. The overarching aim of these programs was to provide an impetus to mental health leadership at district levels that could enable them to upscale public mental healthcare delivery. Upon completion of the program, 109 participants provided a feedback on the content of the program. Majority (98 %) were satisfied with the format of the program in which it was conducted and felt that their expectations were either partially or completely satisfied with appropriate content (93 %). The health authorities (43 %) gained better insights into the magnitude of mental health concerns and agreed that mental health service delivery should scale up. The service providers (17 %) felt the need to upgrade their skills in specialty areas of psychiatry in order to gear up for comprehensive mental health care delivery. Finally, the authors argue that such local level learnings should drive the policy making at the national level.

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.

Impact Evaluation of VKN-NIMHANS-ECHO Model of Capacity Building for Mental Health and Addiction: Methodology of Two Randomized Controlled Trials.

BACKGROUND: Bridging the alarming treatment gap for mental disorders in India requires a monumental effort from all stakeholders. Harnessing digital technology is one of the potential ways to leapfrog many known barriers for capacity building. AIM AND CONTEXT: The ongoing Virtual Knowledge Network (VKN)-National Institute of Mental Health and Neurosciences (NIMHANS)-Extension of Community Health Outcomes (ECHO) (VKN-NIMHANS-ECHO: hub and spokes model) model for skilled capacity building is a collaborative effort between NIMHANS and the University of New Mexico Health Sciences Centre, USA. This article aims to summarize the methodology of two randomized controlled trials funded by the Indian Council of Medical Research (ICMR) designed to evaluate the effectiveness of the VKN-NIMHANS-ECHO model of training as compared to training as usual (TAU). METHODS: Both RCTs were conducted in Karnataka, a southern Indian state in which the DMHP operates in all districts. We compared the impact of the following two models of capacity building for the DMHP workforce (a) the VKN-NIMHANS-ECHO model and (b) the traditional method. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of these two trials.Trial 1 is to evaluate the "Effectiveness of addition of Virtual-NIMHANS-ECHO tele-mentoring model for skilled capacity building in providing quality care in alcohol use disorders by the existing staff of DMHP districts of Karnataka." Hub for trial 1 was set up at NIMHANS and the spokes were psychiatrists and other mental health professionals headquartered in the district level office. Trial 2 assesses the implementation and evaluation of the NIMHANS-ECHO blended training program for the DMHP workforce in a rural south-Indian district of Karnataka state. The hub for trial 2 was set up in the district headquarter of Ramanagaram. Hub specialists are DMHP psychiatrists, whereas spokes are the non-doctor workforce (including auxiliary nurse midwives [ANMs] and accredited social health activists [ASHA] workers) medical officers of primary health centers. The location of the HubHub differs in these two studies. Both trials are funded by the ICMR, Government of India. DISCUSSION: Both these trials, though conceptually similar, have some operational differences which have been highlighted. If demonstrated to be effective, this model of telementoring can be generalized and widely merged into the Indian health care system, thus aiding in reducing the treatment gap for patients unable to access care.

A Report on a Series of workshops on "Mental Health Leadership" for Maharashtra State.

The article is a report on a series of workshops conducted by the National Institute of Mental Health And Neurosciences (NIMHANS), Bengaluru, India in collaboration with the Government of Maharashtra for the local leaders responsible for leading, organizing and delivering public mental health services throughout the state of Maharashtra. The overarching aim of these workshops was to sensitize and orient the participants on the mental health services offered/provided by NIMHANS, the collaborative activities between NIMHANS and Govt. of Karnataka to further the cause of public mental health and also to showcase the scope of DMHP (District Mental Health Program) activities in Karnataka. The professionals were divided into 5 batches as per their specialty or role i.e. Psychiatrists, Psychologists and Social Work besides the health administrators (Civil Surgeons and District Health Officers). Each batch underwent the training 2-3 days. Major areas covered included: Farmers' suicide, programs, policies and laws for the elderly, orientation to the new Mental Health Care Act 2017 and a fully functioning District Mental Health Program (DMHP).

Mental Healthcare Act 2017 - Aspiration to action.

There is no health without mental health. Recently conducted National Mental Health Survey quoted a prevalence of 13.7% lifetime and 10.6% current mental morbidity. To address this mammoth problem, an aspirational law was enacted titled "Mental Healthcare Act, 2017" (MHCA 2017). The act is progressive and rights based in nature. The whole dedicated Chapter 5 on "Rights of the person with mental illness" is the heart and soul of this legislation. However, the act mainly focuses on the rights of the persons with mental illness (PMI), only during treatment in hospital but is not equally emphatic about continuity of treatment in the community. The act fails to acknowledge and foster the role and contribution of family members in providing care to PMI. Although there are many positive aspects to the MHCA 2017, it may impact adversely on the mental health care in India. This article focuses on the shortcomings and challenges of the act and also makes attempts to offer alternatives considering the available resources and ground reality. Concepts such as "Advance directives" and "Nominated representatives" appear to be very attractive, idealistic, and aspirational, but not evidenced based in the Indian context considering the resources. The act fails to make an impact even after 22 months to attain the goal, and will require pervasive efforts to fulfil a purpose that directs its development. This law needs to be amended as per the local resources and requirements of the society.

Cost estimation for the implementation of the Mental Healthcare Act 2017.

The Mental Healthcare Act, 2017 (MHCA) was a step that was essential, once the Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities in 2007. The MHCA looks to protect, promote, and fulfill the rights of persons with mental illness (PMI) as stated in the preamble of the Act. Further, there is an onus on the state to provide affordable mental health care to its citizens. In India, mental health has always been a lesser priority for lawmakers and citizens alike. The rights-based MHCA looks to overhaul the existing system by giving prominence to autonomy, protecting the rights of the mentally ill individuals, and making the State responsible for the care. The decision to make all this happen is commendable. The annual health expenditure of India is 1.15% of the gross domestic product, and the mental health budget is <1% of India's total health budget. This article systematically analyses and describes the cost estimation of the implementation of MHCA 2017, and it is not an estimation of mental health economics. The conservative annual estimated cost on the government to implement MHCA, 2017 would be 94,073 crore rupees. The present study estimation depicts that investing in the implementation of MHCA, 2017 by the government will yield 6.5 times the return on investment analysis benefit. If the State is not proactive in taking measures to implement the MHCA, the rights promised under this legislation will remain aspirational.

Health insurance and mental illness.

One of the important provisions of the Mental Healthcare Act, 2017, in section 21 (4), is the inclusion of "mental illnesses" for health insurance coverage. This is a progressive step toward considering mental illness at par with physical illness, which will, in turn, ensure better access to mental health care. In this context, the article summarizes the concept of "health insurance" and then goes on to talk about various provisions for persons with mental illnesses in India. We also discuss some of the relevant concerns that may arise in this context. Whereas insurance for mental illness is a welcome step toward achieving universal health coverage, there is a need to deliberate on various issues before we can achieve that.

The Rights of Persons with Disability Act, 2016: Challenges and opportunities.

India signed the United Nations Convention on the Rights of Person with Disabilities (UNCRPD) and subsequently ratified the same on October 1, 2007. The UNCRPD proclaims that disability results from an interaction of impairments with attitudinal and environmental barriers which hinders full and active participation in society on an equal basis. Further, the convention also mandates the signatories to change their national laws, to identify and eliminate obstacles and barriers, and to comply with the terms of the UNCRPD. In this regard, the Government of India initially undertook the amendment of laws such as Persons with Disability Act, 1995 (PWD Act 1995). The Rights of PWD Act, 2016 (RPWD Act 2016) replaced the PWD Act 1995 to comply with the UNCRPD. The new act was fine-tuned considering the socio-cultural and local needs of the society, and the available resources. Persons with Mental Illness (PMI) are often stigmatized and discriminated, which hinders their full and active participation in society. This is a much larger issue, especially in women, gender minorities, backward communities, and the poor and the migrated populations. Adding to the complexities, PMIs are often not aware of their illness, refuse the much-needed treatment and often are not in a place to exercise their rights. There is an urgent need to address this issue of attitudinal barrier so that the rights of PMI are upheld. Hence, this article discusses challenges and opportunities in the RPWD Act 2016 from the perspective of PMI.

Prevalence and Clinical and Coercion Characteristics of Patients who Abscond during Inpatient Care from Psychiatric Hospital.

BACKGROUND: Patients absconding from psychiatric hospitals pose a serious concern for the safety of patients and public alike. Absconding is associated with an increased risk of suicide, self-harm, homicide, and becoming "missing" from society. There are only scarce data on profile and outcome of the absconding patients in India. AIMS: To study the prevalence and describe the clinical and coercion characteristics of patients who abscond during inpatient care from an open ward. METHODOLOGY: "Absconding" was defined as patients being absent from the hospital for a period of more than 24 h. This is an analysis of absconding patients out of the 200 admitted patients at a tertiary psychiatric hospital. Descriptive statistic was used to analyze the demographic, clinical, and perceived coercion profile and outcome. RESULTS: The absconding rate was 4.5 incidents per 100 admissions. Most of these patients were males, from a nuclear family, admitted involuntarily, belonging to lower socio-economic status, diagnosed with schizophrenia or mood disorder with comorbid substance use disorder and had absent insight. The MacArthur Perceived Coercion Scale score was 4.58 (±1.44), and 80% of the absconded patients felt subjective coercive experiences in most domains at admission. Out of the 9 absconded patients, 2 patients had completed suicides and one continued to remain untraceable. CONCLUSION: The absconded patients were males; admitted involuntarily; diagnosed with schizophrenia, mood disorder, and comorbid substance use disorder; and had absent insight and high perceived coercion. Absconding patients had the tendency to harm themselves and wander away from home.

Psychiatrist in Court: Indian Scenario.

The impetus for practical exposure to legalities that arise in the context of psychiatry and law is minimal in postgraduate training in psychiatry and curriculum. Those who choose to get trained often do not get first-hand exposure to court proceedings. Law and psychiatry often come into each other's interface, and psychiatry is regulated by the legal system more often than the other specialties in medicine. This article is an attempt to equip the psychiatrist in dealing with instances where they will present themselves in court.

Stressful life events and psychiatric comorbidity in acne-a case control study.

INTRODUCTION: Possibility of a causal influence of emotional stress, on the course of various skin diseases, has been postulated. However, it is still inconclusive about the role of stressful life events in acne. In this background, the present study was carried out to know its role in acne. METHODS: Consecutive one hundred patients who were diagnosed with acne vulgaris in the age group of 12 to 45 years were included. Age and sex matched controls were taken. A semistructured proforma was used to collect sociodemographic details. Stressful life events were assessed using presumptive stressful life event scale. Anxiety was evaluated using Hamilton Anxiety Rating scale and Depression by Hamilton Depression Rating Scale. RESULTS: There was no difference in total stressful life events in past one year between patients and controls. The undesirable life event was present in 65 patients and 50 controls, this difference was statistically significant. Getting married or appearing for exams were the most common stressful life event in patients. Forty patients had comorbid psychiatric illness whereas in controls comorbidity was in 24 and this difference was statistically significant. DISCUSSION: The undesirable stressful life events and psychiatric comorbidity were more in acne patients than in controls.

Feasibility and Utility of Tele-Neurorehabilitation Service in India: Experience from a Quaternary Center.

BACKGROUND: Neurological rehabilitation service in developing countries like India is a great challenge in view of limited resources and manpower. Currently, neurological rehabilitation with a multidisciplinary team is limited to a few major cities in the country. Tele-neurorehabilitation (TNR) is considered as an alternative and innovative approach in health care. It connects the needy patients with the health-care providers with minimum inconvenience and yields cost-effective health care. AIM: The aim of this study was to study the socioclinical parameters, feasibility, and utility of TNR services in India. METHODOLOGY: A retrospective file review of TNR consultations provided through Telemedicine Center at a quaternary hospital-based research center in south India between August 2012 and January 2016. RESULTS: A total of 37 consultations were provided to the patients belonging to four districts of Karnataka. The mean age of the patients was 34.7 (±19.5) years, 23 (62.1%) were aged between 19 and 60 years, and 31 (83.8%) were male. Thirty-one patients (83.8%) had central nervous system-related disorders such as stroke, cerebral palsy, and tubercular meningitis with sequelae or neuromuscular disorders such as Guillain-Barre Syndrome and Duchenne muscular dystrophy. Twelve patients (32.4%) were advised to consult higher centers in the vicinity, and the rest was referred to the district hospital. CONCLUSION: The findings suggest that TNR services are feasible, effective, and less resource intensive in delivering quality telemedicine care in India. More clinical studies are required to elucidate its full utility at different levels and in different parts of the country.