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.

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 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.

Video consultations with "Paper and Pen" health record: A path-breaking solution to troubleshoot acceptability of telemedicine practice in developing countries.

Telemedicine is the delivery of health care from a distance. It also includes research and evaluation of such services using health data which are stored in "Electronic Health Record" (EHR) platforms. EHR has proved to be useful in monitoring health care delivery but setting up of such platforms is tedious and resource-consuming in developing countries. With the recent surge of telemedicine utility during the COVID-19 pandemic, telemedicine has emerged to be pivotal in reaching stranded patients needing care without EHR-based practice. The practice of patient health record (PHR)-based teleconsultations in India has demonstrated how a conventional "paper and pen" method can be combined to popularise telemedicine utility. Thus, use of PHR-based system to maintain health records would prove to be a pragmatic solution for physicians in low-resource settings to improve their reach to a larger population in need for the future.

Video consultations from an Indian academic hospital: First 3 years of experience from telepsychiatric after-care clinic.

Background Continuity of care for psychiatric disorders by conventional in-person consultation by psychiatrists is associated with several challenges. There is a need to develop alternative models of specialist care. We studied our 3 years' experience of live video consultations (VCs) from the tele after-care clinic to patients with psychiatric disorders at an Indian academic hospital. Methods We did a file review of 669 VCs provided to 213 patients in the first 3 years (2017-2019) from the telemedicine centre of a tertiary care academic hospital. We analysed details of sociodemography, clinical profile, tele after-care consultations and outcome. Results Two hundred and thirteen patients (55% men) were enrolled for the tele after-care clinic. The mean (SD) age of the patients was 42.2 (17.29) years and a majority were educated till high school and beyond. Patients with severe and common mental disorders constituted 60.1% and 40%, respectively. Among the total 669 appointments, 542 (81%) VCs were successfully provided; of the remaining, 125 were cancelled and 2 were aborted due to a medical emergency. Medication prescriptions were unchanged in 499 and modified/totally changed in 47 VCs. Conclusion Our large study shows that telepsychiatric after-care is a useful alternative method which can supplement in-person follow-up. Barriers such as distance, cost and medical illness can be overcome using tele after-care clinics for regular follow-ups in stabilized psychiatric patients. There is a need for prospective studies, preferably, randomized controlled trials comparing effectiveness of tele after-care with in-person consultations to assess treatment outcomes.

Accredited Social Health Activist (ASHA) and Her Role in District Mental Health Program: Learnings from the COVID 19 Pandemic.

COVID 19 pandemic has posed challenges for public mental healthcare delivery, particularly in LAMI countries such as India. However, this unique situation has also brought in opportunities to revisit the health system and optimally utilize the available resources. In this brief report, we report one such new initiative in which existing community health workers (CHWs), known as ASHAs (Accredited Social Health Activist) acted as a bridge between patients with mental illness and the District Mental Health Program (DMHP) of Ramanagara district of Karnataka State, India. They maintained continuity of care of 76 patients by delivering mental healthcare services to the patients' doorstep. This has paved the way to rethink and revisit their role in public mental healthcare delivery not only during COVID 19 times, but also beyond.

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.

Identification of Psychiatric Disorders by Rural Grass-Root Health Workers: Case Series & Implications for the National Mental Health Program of India.

Auxiliary Nurse Midwife (ANMs) and Accredited Social Health Activists (ASHAs) are well suited to cater to the mental health needs of the communities. Integrating primary mental health care into the general healthcare is one of the important objectives of the District Mental Health Program (DMHP) to reduce the treatment gap. As a part of an ICMR funded trial to evaluate the effectiveness of NIMHANS-ECHO blended training program, the ASHAs and ANMs were trained to identify and refer cases from the community. We aim to describe a series of cases identified by those workers from the community, highlighting their importance in our health care system.

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.

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.

Duration of Pupillary Unresponsiveness to Light: A Physiological Adjunct to Electroencephalography and Motor Seizure Duration Monitoring During Electroconvulsive Therapy.

BACKGROUND: During electroconvulsive therapy (ECT) sessions, we observed that the time taken for the return of pupillary response to light (ROPL) outlasted both the electroencephalography (EEG) and the motor seizure duration after the delivery of the electrical stimulus to produce convulsions. OBJECTIVE: The objective of this study was to investigate whether ROPL can be used as a marker of cessation of seizure activity in the brain after ECT and also to study the effect of atropine premedication on seizure activity during ECT. METHODS: Forty-one patients underwent 82 sessions of ECT in a cross-over design study. The duration of motor seizure, EEG seizure, and time for ROPL was observed and compared. RESULTS: The ROPL consistently outlasted EEG and motor seizures; the difference in their mean durations was statistically significant P < 0.05. There was good correlation among the 3 parameters. Atropine premedication did not alter the seizure activity and ROPL after ECT. CONCLUSIONS: The ROPL after ECT stimulus is a good bedside monitor for termination of seizure activity and can be a valuable adjunct to surface EEG in monitoring the duration of epileptic activity after delivery of ECT.

Antipsychotic treatment, psychoeducation & regular follow up as a public health strategy for schizophrenia: Results from a prospective study.

BACKGROUND & OBJECTIVES: In low- and middle-income countries such as India, a feasible public health strategy could be to ensure continuous antipsychotics and psychoeducation for those with schizophrenia. Whether such a strategy favourably influences its course and outcome is not well-studied. The objectives of this study were to examine these issues in a cohort of patients with schizophrenia in a rural south Indian taluk (an administrative block). This cohort was part of a community intervention programme running in the place since the past one decade. METHODS: A total of 201 patients were assessed after an average of four years of follow up. Psychopathology, disability and course of illness were assessed using Positive and Negative Syndrome Scale (PANSS), Indian Disability Evaluation and Assessment Scale (IDEAS) and Psychiatric and Personal History Schedule (PPHS), respectively. Interventions included ensuring continuous antipsychotic treatment and low-intensity psychoeducation. RESULTS: One hundred and forty two [70.6%; 95% confidence interval (CI): 64.35-76.95] of the 201 patients achieved clinical remission by the end of follow up period (four years); 140 (69.6%; 95% CI: 63.29-76.07) had satisfactory outcome (42.3% best outcome and 27.4% intermediate outcome). There was a significant reduction in the proportion of patients with disability [134/201 (66.7%) at baseline; 55/201 (27.3%) at follow up; PInterpretation & conclusions: Treatment with antipsychotics and psychoeducation can favourably influence the course of schizophrenia and reduce disability in a substantial proportion of patients. Structured psychosocial interventions may be indicated in the significant minority who show suboptimal outcome with this strategy.

Concomitant Anticonvulsants With Bitemporal Electroconvulsive Therapy: A Randomized Controlled Trial With Clinical and Neurobiological Application.

BACKGROUND: Electroconvulsive therapy (ECT) is an effective treatment for major affective disorders. The combined use of ECT and anticonvulsant mood stabilizers is a common clinical scenario. There is dearth of systematic studies on the use of this combination with regard to clinical or cognitive outcomes. OBJECTIVE/HYPOTHESIS: We aimed to compare clinical improvement and cognitive adverse effects between patients who received only ECT versus those who received ECT and anticonvulsants. We hypothesized that improvement would be fastest in patients who received only ECT. METHODS: We conducted a randomized controlled trial in which patients prescribed ECT while being treated with anticonvulsants were randomized into 3 groups: full-dose (FD), half-dose (HD), and stop anticonvulsant. A blind rater assessed clinical improvement in patients using rating scales [Young's Mania Rating Scale (YMRS) and Clinical Global Impression] for clinical improvement and cognitive adverse effects (Postgraduate Institute memory scale). Analysis was done using mixed-effects modeling to delineate differences in clinical and cognitive outcomes across the 3 arms of the study over the course of ECT. RESULTS: Of the 54 patients recruited, 36 patients went into treatment allocation arms per the initial randomization plan. The main anticonvulsants prescribed were sodium valproate and carbamazepine. Patients in the 3 groups were comparable on clinical features. The most common diagnosis was bipolar affective disorder-with current episode of mania. Overall, there was no difference across the 3 groups in final clinical outcome scores (YMRS and Clinical Global Impression) when analyzed as intention to treat (ITT) or "as treated." In both analyses, group × time interaction was significant when comparing trend of YMRS scores between the FD anticonvulsant group and the HD group from baseline to last ECT (P = 0.0435 in ITT and P = 0.0055 in as treated). Patients in the FD group improved faster than those in the HD group. There were no differences across the 3 groups with regard to their cognitive adverse effects in the ITT analysis; "as-treated analysis" showed the HD patients to have performed poorly on some domains. Seizure parameters showed no significant difference across the 3 groups. CONCLUSION: This is a preliminary prospective study examining whether coprescription of anticonvulsants with ECT affected clinical or cognitive outcomes. The most important takeaway point from this study is the significant reduction in YMRS scores when ECT was given with FD anticonvulsant compared with halving the dose (HD) of anticonvulsant. This difference was shown in both ITT and as-treated analysis. There is a need for more prospective studies to examine this clinical question.

Cognitive deconstruction of parenting in schizophrenia: the role of theory of mind.

OBJECTIVE: Schizophrenia patients experience impairments across various functional roles. Emotional unresponsiveness and an inability to foster intimacy and display affection may lead to impairments in parenting. A comprehensive cognitive understanding of parenting abilities in schizophrenia has the potential to guide newer treatment strategies. As part of a larger study on functional ability in schizophrenia patients, we attempted a cognitive deconstruction of their parenting ability. METHODS: Sixty-nine of the 170 patients who participated in a study on social cognition in remitted schizophrenia were parents (mean age of their children: 11.8 ± 6.2 years). They underwent comprehensive assessments for neurocognition, social cognition (theory of mind, emotion processing, social perception and attributional bias), motivation and insight. A rater blind to their cognitive status assessed their social functioning using the Groningen Social Disabilities Schedule. We examined the association of their functional ability (active involvement and affective relationship) in the parental role with their cognitive performance as well as with their level of insight and motivation. RESULTS: Deficits in first- and second-order theory of mind (t = 2.57, p = 0.01; t = 3.2, p = 0.002, respectively), speed of processing (t = 2.37, p = 0.02), cognitive flexibility (t = 2.26, p = 0.02) and motivation (t = 2.64, p = 0.01) had significant association with parental role dysfunction. On logistic regression, second-order theory of mind emerged as a specific predictor of parental role, even after controlling for overall functioning scores sans parental role. CONCLUSIONS: Second-order theory of mind deficits are specifically associated with parental role dysfunction of patients with schizophrenia. Novel treatment strategies targeting theory of mind may improve parenting abilities in individuals with schizophrenia.

Negative symptoms mediate the influence of theory of mind on functional status in schizophrenia.

We aimed to assess the relationship between social cognition, neurocognition, negative symptoms and functional status in a homogeneous schizophrenia patient group remitted from positive symptoms. Sixty patients underwent assessments of social and neurocognition dimensions recommended by expert panels. A blind rater assessed their functional status. Second order theory of mind (ToM) and negative symptoms had significant correlations with functional status. A bootstrapping analysis used to test for specific mediation models revealed that the effect of second order ToM on functioning was mediated by negative symptoms. Future studies should examine if targeted remediation of ToM improves negative symptoms and thus functioning.

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.

Development of preparedness to respond to intimate partner violence scale among mental health professionals.

Objectives: Violence against women has been associated with serious health and mental health consequences. Health-care professionals play an important role in screening and providing care and support to victims of intimate partner violence (IPV) in the hospital setting. There is no culturally relevant tool to assess the mental health professional (MHP) preparedness to screen for partner violence in the clinical setting. This research aimed towards developing and standardizing scale to measure MHP preparedness and perceived skills in responding to IPV in the clinical setting. Materials and Methods: The scale was field tested with 200 subjects using consecutive sampling at a tertiary care hospital. Results: The exploratory factor analysis resulted in five factors constituting 59.2% of the total variance. The internal consistency Cronbach alpha 0.72 for the final 32-item scale was highly reliable and adequate. Conclusion: The final version of the Preparedness to Respond to IPV (PR-IPV) scale measures MHP PR-IPV in the clinical setting. Further, the scale can be used to evaluate the outcome of IPV interventions in different settings.

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.

Reproductive rights of women with intellectual disability in India.

The reproductive rights of women with intellectual disability (WID) are a matter of concern for all stakeholders, including the woman herself, caregivers, guardians and her treating physicians. The judicial system often calls upon psychiatrists to opine regarding the "capacity to consent" of a WID to procedures such as medical termination of pregnancy and permanent sterilisation. Apart from physical and obstetric examinations, assessment of mental status and intelligence quotient (IQ) are also carried out to facilitate an understanding of the above issue. The Rights of Persons with Disabilities Act, 2016, (RPwD) and the Mental Healthcare Act, 2017, elucidate what constitutes free and informed consent as well as how to assess capacity. The assessment process of "capacity to consent" to reproductive system procedures among WID is important and can guide clinicians. Before assessing capacity, the treating physicians should educate a WID with appropriate information on the proposed procedure, its risks and benefits through various means of communication and then evaluate the "capacity to consent" to the procedure. This article summarises the provisions of the existing legislations on the reproductive rights of WID and puts forward guidance for clinicians on how to approach the issue.