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.

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.

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.

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.

Dual Clinical Collaborator: A Pragmatic Role of nurses from developing countries

Collaboration is crucial in Professional nursing practice. Nurses act as a liaison between physicians and patients and their family members. Thus, it is vital to define the collaborative role of nurses in developing countries. The authors discuss pragmatic nurses' role by adopting the Dual Clinical Collaborator model to ensure offering the quality of care to their clients. Nursing is a healthcare profession that focuses on the care of individuals and their families to help them recover from illness and maintain optimal health and quality of life.(1) Health Care Professionals (HCPs) work together to provide quality health care and accomplish common goals. As healthcare delivery is becoming more complex, collaboration among healthcare workers and the patient can be a path to improve the quality of healthcare services. According to Walker and Avant's method, the conceptual definition of collaboration in nursing is an intra professional or interprofessional process by which nurses come together and form a team to solve patient care or healthcare system problem with members of the team respectfully sharing knowledge and resources.(2) Thus, collaboration is crucial in everyday professional nursing practice and should be considered a core value of nursing.(3)

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.

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.

Embracing Technology for Capacity Building in Mental Health: New Path, Newer Challenges.

Technology driven capacity building initiatives are the way to break the barrier of shortage of mental health human resources in India. This new path, while is a welcome step, comes with its own set of challenges. In one prototypic project that is being implemented in Ramanagara District of Karnataka, a south Indian state, we encountered many such issues. They ranged from issues related to availability of dedicated space to set up the hub-studio, inconsistent internet connectivity (particularly in remote areas) and inadequate digital literacy among the grassroot community health workers who hail from villages. This article summarises these challenges and ends by looking into ways and means of overcoming them.

Prescribing Psychotropics: Perspective From Telepsychiatry Operational Guidelines 2020.

As telemedicine gained both importance and momentum following COVID -19 pandemic, Telemedicine Practise Guidelines (TPG) March 2020 was notified by the Central Government of India. Following the above, the Indian Psychiatrists Society, Telemedicine Society of India (TSI) and National Institute of Mental Health and Neurosciences (INI), Bangalore came together to address the specific needs of Psychiatrists practicing tele consultations, there by releasing Telepsychiatry Operational Guidelines 2020. This article discusses the guidelines outlines in the above documents with respect to prescribing psychotropics. We have discussed the thought process behind formulation of Telepsychiatry Operational guidelines, the challenges that may arise while following the above guidelines with possible solutions.

Telepsychiatry and Medical Insurance: Comparative Perspectives Between India and the United States.

Telepsychiatry is a cost-effective alternative to in-person psychiatric consultations. The COVID-19 pandemic brought about a sharp spike in the utilization of telepsychiatry due to ongoing restrictions on gatherings and traveling. In recognition of the importance of telemedicine in general, and telepsychiatry specifically, telemedicine practice guidelines and telepsychiatry operational guidelines have been released. Due to the rising trend in telemedicine, the Insurance Regulatory and Development Authority of India (IRDIA) incorporated teleconsultation health insurance coverage at a level on par with regular in-person consultations. In contrast, in the United States of America, private insurance coverage for telepsychiatry has been in vogue for some time. In this paper we draw comparisons between India and the United States on telepsychiatry and health insurance. We compare the evolving regulatory policies of these two countries in relation to existing insurances plans that are available, the challenges in implementation of new regulations and the possible ways to overcome the challenges to make telepsychiatry affordable to all.