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 The Consumer Protection Act, 1986, was later repealed and replaced by the Consumer Protection Act, 2019.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.

The rationale and guiding principles to design a psychiatric curriculum for primary care nurses of India.

Background: The National Mental Health Survey reports a huge treatment gap for all mental disorders. There is an acute shortage of mental health professionals in India. Hence, there is a dire need to support task-shift interventions by nurses in providing non-pharmacological interventions for persons suffering from mental health issues. The traditional psychiatric nursing curriculum emphasizes nurses' knowledge and skills rather than their competency in providing mental health care. We designed an innovative, digitally driven, modular-based primary care psychiatry program for nurses (PCPP-N) to incorporate mental health with physical health and emphasize redesigning nursing practice. In this paper, we discuss the rationale and guiding principles behind designing the curriculum of PCPP-N. Discussion: The PCPP-N program is based on nine guiding principles to provide skill-based, pragmatic, and feasible modules of a higher collaborative care quotient (CCQ) and translational quotient (TQ) that are essential for upskilling primary care nurses. In this program, nurses are trained through telemedicine-based 'on-consultation training' augmented with collaborative video consultations. A tele-psychiatrist/tele-psychiatric nurse will demonstrate how to screen, identify, and plan treatment for patients with psychiatric disorders from patients coming for general medical care using the manual Clinical Schedules of Primary care psychiatry Nursing (CSP-N). The CSP-N manual includes a screener, simplified diagnosing guidelines relevant for nurses and primary care settings, nursing management, pharmacological management, and related side effects, counseling, and follow-up guidelines. This program helps the nurses in identifying the most commonly prevalent adult psychiatric disorders presenting to primary care. Conclusion: This PCPN curriculum contains pragmatic modules with higher CCQ and TQ. This curriculum is dynamic as the learning is interactive. Upskilling primary care nurses in integrating mental health with physical health may reduce the mental health burden. Further, the policymakers and administrators plan to integrate mental health along with physical health in national health programs.

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.

Cost of Illness Analysis of Common Mental Disorders: A Study from an Indian Academic Tertiary Care Hospital.

Background: The cost of illness (COI) for common mental disorders (CMDs) that include depression, anxiety, and somatoform disorder is less studied in India. Hence, we studied the COI and disability of CMDs and their relationship in patients with depression, anxiety, and somatoform disorders. Methods: In this cross-sectional study, we recruited 220 patients (110 with depression, 58 with anxiety disorders, and 52 with somatoform disorders) and evaluated disability using the Sheehan Disability Scale (SDS). The schedule for the cost of illness (S-COI) was used for evaluating COI for the last year. Results: The annual COI of CMDs from the patient perspective was ₹21,620 (interquartile range [IQR], ₹47,761; ≈US$290). The median annual direct COI was ₹4,907 (IQR ₹7,502), and indirect COI was ₹12,900 (IQR ₹37744). The direct COI was 18%, whereas the indirect COI was 82%. The direct and indirect COI in the three groups were similar. In all three groups with ongoing treatment, the mean scores indicated a mild level of disability. Total and indirect COI, but not the direct COI, correlated positively with the severity of illness and disability. Conclusion: All the CMDs with ongoing treatment are associated with a mild level of disability and are a significant financial burden, with higher indirect costs.

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.

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.

Development and Validation of Clinical Schedule for Primary Care Psychiatric Nursing (CSP-N) for Primary Care Nurses.

Introduction: As per the World Health Organization's mental health report for 2022, nearly a billion people have mental health issues, and 82% of them are in low and middle-income countries where mental health services are largely absent. For the successful integration of mental health into primary health care, proper training and education of primary care professionals are mandatory. Primary care nurses are in an excellent position to screen, identify, dual collaboration for treatment planning/referral, and follow-up of persons with mental illness (PMI), but they often lack the confidence and competence to tackle mental health problems. The study aimed to develop and validate the clinical schedule for primary care psychiatric nursing (CSP-N). Materials and Methods: It is conducted in two phases: the development and validation phases. An extensive literature search has been conducted, and the ten themes derived from the two-focused group discussions and three-direct one-to-one interviews and input from mental health experts were used to design the CSP-N. The CSP-N was checked for content validity by a panel of 17 experts using the item-level content validity index (I-CVI) and the scale-level content validity index (S-CVI). Results: The draft version 1 of the CSP-N showed high content validity for individual items (I-CVI range: 0.82 to 1.00) and high overall content validity (S-CVI = 0.95), and suggestions from the experts were incorporated. The CSP-N was developed in four modules. The single-measure two-way mixed absolute agreement ICC value was calculated (for 32 subjects) for the reliability test, and the ICC value was 0.97 with a 95% CI (0.94, 0.99). Conclusions: Using an iterative approach, the development and validation of the CSP-N demonstrated high I-CVI and S-CVI for screening and identification, dual collaboration for the treatment plan, referral, and follow-up of a person with mental illness by the nurses in the community.

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.

Impact of Technology Driven Mental Health Task-shifting for Accredited Social Health Activists (ASHAs): Results from a Randomised Controlled Trial of Two Methods of Training.

Mental health task shifting is a potential way to address the burgeoning treatment gap for mental illness. Easily available and accessible digital technology can be utilised to continuously engage grassroot level health workers (for example, Accredited Social Health Activists (ASHAs). However, the impact of such a strategy is not yet systematically evaluated. In this randomised controlled trial, longitudinal hybrid training of ASHAs [1 day in-person classroom training and seven online sessions (ECHO model), aimed to screen and refer to commonly prevalent mental health issues in communities] was compared with traditional one-day in-person classroom training. ASHAs (n = 75) from six Primary Health Centres in Ramanagara district, Karnataka, India were randomized into study (SG-ASHAs) and control (CG-ASHAs) groups. After excluding drop-outs, 26 ASHAs in each group were included in the final analysis of the scores on their Knowledge, attitude, and practices (KAP) in mental health. Two house-to-house surveys were conducted by both groups to identify and refer possible cases. The number of screen positives (potential persons with mental illnesses) and the KAP scores formed the outcome measures. Online sessions for SG-ASHAs were completed over 18 months, the COVID-19 pandemic being the main disruptor. SG-ASHAs identified significantly higher number of persons with potential alcohol use disorders [n = 873 (83%); p ≤ 0.001] and common mental disorders [n = 96(4%); p = 0.018], while CG-ASHAs identified significantly higher number of those with potential severe mental disorders [n = 61(61.61%); p ≤ 0.001]. As regards KAP, after controlling for baseline scores, the time effect in RMANOVA favoured SG-ASHAs. Mean total KAP score increased from 16.76 to18.57 (p < 0·01) in SG-ASHAs and from 18.65 to 18.84 (p = 0.76) in CG-ASHAs. However, the Time-group interaction effect did not favour either (F = 0.105; p = 0.748). Compared to traditional training, mentoring ASHAs for extended periods is more impactful. Easily accessible digital technology makes the latter feasible. Scaling up such initiatives carry the potential to considerably improve treatment access for those in need.

Ethical and legal issues concerning COVID 19 vaccinations in persons with mental illness in India.

Mental healthcare in India faces severe challenges amid the ongoing pandemic. India runs the largest vaccination drive globally, including booster doses to rapidly vaccinate its population of over a billion. As persons with mental illness are at greater risk of adverse outcomes from COVID 19, they need prioritized access and administration of these vaccines. This manuscript examines the current legislation and identifies how the legal and ethical frameworks can prioritize COVID 19 vaccinations for persons with mental illness in India through a review of the various legislations of India concerning persons with mental illness and judicial judgments concerning the pandemic and vaccination. Subsequently, we discuss ethical and legal challenges associated with vaccination in this vulnerable population and possible solutions. Based on the current review, the authors recommend the guidelines for capacity assessment for vaccination decisions and discuss existing legal frameworks relevant to the vaccination of persons with mental illness.

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.

The Legality and Ethical Issues of Certifying Laypersons as Mental Health Counselors in India.

Background: The burden of mental health conditions and consequent disability impacts are felt most in low- and middle-income settings. These settings are constrained by the limited availability of resources to provide even essential aspects of mental health care (MHC). Task shifting and sharing interventions have shown promise in delivering community-based MHC across such low-resource settings. Some counseling tasks such as friendship bench interventions have been successfully shifted to laypersons. However, ethical and legal concerns regarding laypersons' incorporation in MHC delivery systems have not been examined. Purpose: To examine the ethical and legal concerns surrounding the certification of laypersons as community-based mental health counselors. Method: We undertook an academic review of various legislations pertinent to MHC service delivery and the certification of allied health care professionals to inform on acceptable and tenable strategies toward incorporating such a task-shifted intervention. Conclusion: Scaling up the training of human resources to address access problems can be the first step in addressing the MHC access and treatment gaps. The certification of laypersons as community-based mental health counselors, although legally tenuous, can be pioneered by tertiary-level MHC institutions. This certification has sound ethical justification and is a progressive step toward realizing universal mental health coverage.

The rationale and guiding principles to design a psychiatry curriculum for primary care doctors of India.

Background Integrating psychiatric care into the general practice of primary care doctors (PCDs) is necessary to overcome the shortage of human resources to cater to the burgeoning public mental health needs of India. The traditional psychiatry curriculum is often top-down and specialist-based that contributes little in terms of skill quotient. We designed an innovative, digitally driven, distance education-based, part-time, modular-based Primary Care Psychiatry Programme (PCPP, skill-based). It is being implemented across many states of India to equip PCDs with skills to provide first-line psychiatry treatment. We discuss the rationale and guiding principles behind designing the curriculum of PCPP. Discussion There are nine guiding principles behind designing and implementing PCPP to provide pragmatic, acceptable, feasible modules of higher translational quotient (TQ) that are essential to upskill PCDs. There is a shift in training the location of PCDs in their live brief general consultations utilizing innovative telemedicine-based 'on-consultation training' (OCT) augmented with collaborative video consultations. A monolithic treatment protocol-driven, trans-diagnostic approach is used to design a concise, all-inone, point-of-care manual containing a culturally sensitive, rapid, validated screener and taxonomy, called 'Clinical Schedules for Primary Care Psychiatry'. This incorporates the PCDs' style of clinical practice that helps in picking up the most commonly prevalent adult psychiatric disorders presenting to primary care. Conclusion This PCPP curriculum contains pragmatic modules with higher TQ. This curriculum is dynamic as the learning is bi-directional. This can be used by policy-makers, innovators and academia for integration with national health programmes such as those for non-communicable diseases and reproductive and child health.

Free legal aid in hospitals for persons with mental illness: Is it helpful? An Indian prospective study.

Background: Legislative backing exists to set up free legal aid clinics in psychiatric hospitals to provide legal assistance to their patients. Aims: This study aimed to assess the utility of a free legal aid clinic running inside a mental health establishment. Methods: In this prospective study, 71 subjects (chosen via convenience sampling) were recruited. Assessments were carried out at baseline and two months after intake. Legal needs and the legal outcomes were assessed. Results: Most of the legal issues were either family-related (50.7%) or civil issues (28.2%). A majority of patients (64.4%) had implemented the advice given at the clinic. Those who had implemented the advice had a better legal outcome, defined as either resolution of the legal issue or that the legal issue was in an active proceeding compared to those who had not implemented the advice (P = 0.007). Conclusion: The provision of free legal aid services in mental health establishments would benefit patients.

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.