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

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

Development and training of mental health professionals in providing psychological intervention and support for women survivors of intimate partner violence - A pre-post evaluation study

CONTEXT

Health care providers play a significant role as they are the first contact for seeking help for intimate partner violence (IPV) survivors.

AIMS

This research aimed toward developing a comprehensive culturally appropriate intervention package for the mental health professionals (MHPs) to provide psychological intervention and support for women survivors of IPV and test the training impact on the level of attitude, knowledge, and preparedness to respond to IPV disclosure among MHPs.

SETTINGS AND DESIGN

A single group, pre-post intervention study, was conducted at Tertiary Mental Health Hospital in the Southern part of India, Bengaluru.

MATERIALS AND METHODS

A total of 30 MHPs were recruited for the study using purposive sampling. MHP Attitude, Knowledge, Preparedness to Manage IPV (MAP-IPV) questionnaire was used to collect the data.

STATISTICAL ANALYSIS USED

Descriptive statistics were used to assess the sociodemographic characteristics of the participants. The pre-post evaluation was analyzed using the independent "t" test by comparing the means scores of the MAP-IPV questionnaire. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) - 20 version of the software.

RESULTS

The results revealed a lack of attitude, knowledge preparedness, and available resources materials among MHPs in addressing IPV cases. Pre-post evaluation showed statistically significant improvement in attitude, knowledge, and preparedness to identify and respond to IPV disclosure among MHPs after the intervention program.

CONCLUSION

The comprehensive IPV intervention package effectively brings gain in attitude, knowledge, and preparedness among MHPs in addressing survivors of IPV. Practice guidelines and clear referral pathways following IPV disclosure need to be implemented to support the gains made through the training.

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.

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.

Developing a Screening Tool for Mental Health Professionals for Measuring Intimate Partner Violence among Women with Mental Illness at Tertiary Care Setting

Background  Intimate partner violence (IPV) is the major public health issue seen in all cultures. Mental health professionals play a significant role in screening IPV and providing needed care and support to the survivors. There is a dearth of scale to measure comprehensively different dimensions of violence. The study aimed to develop a screening tool for measuring IPV among women with mental illness (WwMI) in India.

Methods  The newly developed IPV scale was administered to 200 WwMI at a tertiary care hospital.

Results  The factor analysis revealed four factors constituted 67.15% of the variance. The internal consistency Cronbach's α (0.92) and split-half reliability coefficient value (0.80) for the final 31-item IPV scale were found to be highly adequate and reliable.

Conclusion  Psychometric properties of scale found to be an effective tool for screening IPV among WwMI by mental health professionals and planning effective intervention strategies to prevent the IPV.

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

CONTEXT

Over the years, telepsychiatry services have expanded in many institutes. The Telemedicine Practice Guidelines and Telepsychiatry Operational Guidelines (TPOG) released in 2020 have been received by the fraternity with a mixture of apprehension, relief, and dissatisfaction on the list of drugs provided in Lists O, A, B, and C. Many psychiatrists have raised the issues of having a consensus in the formulation of List A.

AIMS

To draw consensus on the medications that can be listed in Lists O, A, B, and C in TPOG-2020.

SETTINGS AND DESIGN

This was an online survey with ethics approval by the Indian Psychiatric Society Ethics Review Board. All psychiatrists, who are members of the Indian Psychiatric Society and whose E-mail address was available with the society, were sent the survey link by E-mail.

METHODOLOGY

Opinions and suggestions on Lists O, A, B, and C of TPOG-2020 and reasons for the suggestions were collected.

STATISTICAL ANALYSIS USED

Frequency, percentages, mean, and standard deviation were calculated. T-test and Chi-square tests were used to see the influence of demographics on the concurrence of the lists.

RESULTS

Responses from 340 responders were analyzed. Majority of the responders agreed that List O (277, 85.5%), List B (263, 82.4%), and List C (223, 69%) are apt except for List A (162, 50.3%).

CONCLUSIONS

This online survey showed that majority of the responders agreed to the lists except for List A. The approach taken to include the medications in List A, which was to include the essential drugs, has various benefits. However, the lists are not final, and the results of this survey may become an impetus to modify the list in the next edition of TPOG.

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.

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.

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

CONTEXT

Telepsychiatry is being practiced in India for many years but was formalized only in 2020. It has many advantages and disadvantages.

AIMS

This study aimed to understand the perceived advantages and disadvantages of telepsychiatry practices in India.

SETTINGS AND DESIGN

An online survey with ethics approval by the Indian Psychiatric Society (IPS) Ethics Review Board. All psychiatrists who are members of the IPS and whose email address was available with the society were sent the survey link by email.

METHODOLOGY

Information about existing telepsychiatry consultation practices in India and perception of advantages and disadvantages by the practitioners were collected between June and July 2020.

STATISTICAL ANALYSIS

Frequency, percentages, mean, and standard deviation were calculated.

RESULTS

Responses by 340 responders were analyzed. Majority of the responders felt that telepsychiatry would provide easy accessibility to mental health services (n = 283, 83.24%) and would lead to less exposure to infections (n = 222, 65.29%). Half of the responders (n = 177, 52.06%) felt that there would be an increased doctor shopping resulting in poor care and nearly three-fourth (n = 245, 72.06%) felt that mental health professionals would fall into a problem while dealing with a suicidal or a homicidal patient. Some expressed that the inability to do physical and central nervous system examinations could lead to missing out comorbidities. About one-third (n = 117, 36.56%) felt that the patient recording the consultation would be a legal issue.

CONCLUSIONS

This online survey showed that psychiatrists perceive many advantages and some disadvantages in practicing telepsychiatry.

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.

Addressing the mental health concerns of migrant workers during the COVID-19 pandemic: An experiential account

The COVID pandemic has affected the world in a drastic manner taking a toll of not only human lives but also the economy and lifestyle. Of all the population suffering, the underprivileged and vulnerable groups have faced the maximum economic burden. Within India, an ample quota of people migrates annually for elementary occupations in service, sales, building and domestic industries. Generally, they are exposed to discrimination, work-rights exploitation and job insecurity. The onset of COVID 19 has accentuated these issues in unprecedented ways. The Apex Court of the country took note of this plight and gave directions to the governments to take care of the immediate needs of the migrant workers. This article attempts to reflect the mental health concerns of the migrant workers who were temporarily sheltered at relief camps across Bengaluru city in the state of Karnataka, during the ongoing COVID pandemic. The article ends with giving recommendations.

Intimate Partner Violence, Lifetime Victimization, and Sociodemographic and Clinical Profile of Women with Psychiatric Illness at a Tertiary Care Psychiatric Hospital in India

BACKGROUND

Intimate partner violence (IPV) is one of the major public health problems. Little is known about the extent of violence experienced, its severity, or history of childhood abuse or exposure to intergenerational family violence in women with mental illness.

METHODS

One hundred women seeking in-patients (IP) or out-patients (OP) services at a tertiary care psychiatric setting were recruited using consecutive sampling. IPV Questionnaire and Danger Assessment Questionnaire were administered.

RESULTS

The data revealed a moderate level of IPV experienced by the women. In their childhood, more than one-third had undergone physical abuse by their fathers and witnessed violence by fathers toward mothers.

CONCLUSION

Screening for intimate violence is essential in women attending mental health settings.

Parental consanguinity among patients with schizophrenia in a rural community of South India: A clinical and genetic investigation

BACKGROUND

Studies from certain regions of the world indicate that consanguineous marriages are a risk factor for the development of schizophrenia in offspring. However the evidence is inconsistent partly due to methodological limitation of which hospital based recruitment contributing to significant bias. The studies from the Indian subcontinent, is scarce, where rates of consanguinity is high.

METHODS

The schizophrenia patients living in a geographically defined rural south Indian community and randomly selected controls dwelling in the same community sharing sociocultural, economic and lifestyle factors were recruited. They were assessed for parental consanguinity using the clinical interviews as well as DNA-based estimates. The latter was conducted by calculating the coefficient of inbreeding 'f'. A participant was considered to have consanguineous parentage if his/her parents shared a common ancestor no more remote than a great-great-grandparent, corresponding to DNA-based estimates of 'f' ≥ 0.0156.

RESULTS

The rates of parental consanguinity assessed by clinical interview were comparable in both groups (Cases: 10.71 %, Controls: 7.25 %; χ² = 0.493, p = 0.4825). However, DNA-based rates of parental consanguinity showed that 'f' was significantly higher among cases than controls (Mann-Whitney U = 11315.5; p = 0.022). Seventy-five cases (62.5 %) and 108 control participants (48.6 %) had 'f' ≥ 0.0156 (χ² = 6.008; p = 0.014). The results were consistent across different quality control measures.

CONCLUSION

Schizophrenia is associated with higher parental consanguinity, suggesting a role for multiple recessive risk alleles in its etiology. Replication in future studies in diverse settings would add further strength to this.

Public Health Perspectives of Geriatric Mental Health Care

BACKGROUND

In older adults (aged 60 years and above), mental health problems are gaining public health importance because of the increasing prevalence, disease burden, disability, morbidity, and mortality. Epidemiological studies on major mental health disorders such as depression and dementia in older adults have contributed to a better understanding of the distribution and determinants of these conditions. Identifying potential risk factors has stimulated interventional research on preventing these conditions under the public health framework towards their management. The increasing burden of geriatric mental health conditions like dementia in developing countries like India can contribute to significant challenges if there is no adequate strengthening of the public health response. This includes scaling up the measures of prevention, public awareness, early diagnosis, and quality health and social care equitably available to all sections of the population. The Decade of Healthy Ageing (2021-2030) provides the opportunity for concerted and coordinated initiatives to improve intrinsic capacity (physical and mental) and offer an age-friendly environment to enhance the functional ability of all older adults.

METHODS

This article reviews the critical public health issues related to geriatric mental health in India.

Palliative Care and Legal Issues in Geriatric Psychiatry

There is an increased risk of debilitating illnesses that often have no curative treatment with aging. The mainstay of treatment in many such conditions is palliative care: a holistic approach focused on preventing and relieving physical, psychosocial, legal, ethical, and spiritual problems. It involves the facilitation of end-of-life care decisions aimed at relieving distress and improving quality of life. In this article, the authors discuss the role of mental health professionals in legal issues related to palliative care in the elderly around decision-making, right to autonomy, euthanasia, and advanced directive. The cognitive decline associated with aging and mental health issues in the palliative care setting of an individual such as dementia, depression, and hopelessness, and impact on the family members like burnout may influence the overall capacity of that individual to make decisions about their treatment. While an individual has a right to self-determination and autonomy, withholding or withdrawing treatment has many legal and ethical implications, more so in those with incapacity, especially in India due to the absence of uniform legislation. The decision to withhold or withdraw treatment might be a restrictive choice due to limited options in a setting with a lack of palliative care options, poor psychosocial support, nonaddress of mental health issues, and lack of awareness. As the right to health is a constitutional right, and the right to mental health is legally binding under Section 18 of the Mental Health Care Act 2017, systematic efforts should be made to scale up services and reach out to those in need.

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.

Maintenance and Welfare of Parents and Senior Citizens Act 2007: A Critical Appraisal

BACKGROUND

The sociocultural changes associated with globalization and development have weakened the traditional values and family support systems for senior citizens (age 60 years and above). There is an increase in the prevalence of elder abuse and difficulties in getting appropriate care and support. This has mandated legal measures to protect the rights of the senior citizens and provide them care and support by the family and other stakeholders. Consequent to being the signatory for the "Madrid International Plan of Action on Ageing, 2002," several countries, including India, have introduced legislation for the social protection of senior citizens. "The Maintenance and Welfare of Parents and Senior Citizens(MWP) Act, 2007" is an important legislation in India to safeguard the elderly from exploitation and abuse.

METHODS

This article critically evaluates the implementation of the MWP Act, 2007, and the related challenges in protecting senior citizens from abuse. The article will also highlight the proposed amendments in the Act to strengthen the effective implementation of legal protection for senior citizens and ensure their well-being and dignity.

CONCLUSIONS

The MWP act is an important legal measure to ensure mainatinence and welfare of senior citizens and protect them from abuse and neglect. There is an immediate need to incorporate the necessary amendments so that the act gets more pragmatic value and becomes and important tool for elderly care and protection and reduce vulnerabilities and ensure holistic care with support in various bio-psycho-social domains.

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.

Civil responsibility in Geriatric Psychiatry

Mental health issues impair decision-making capacity, more so in elderly people. Impaired decision-making capacity can make person unfit to enter into various civil deeds and agreements. Such civil deeds can include guardianship, property transaction, holding a bank account, having voting rights, making a will, donating an organ, etc. This article focuses on importance of mental health in entering into above-mentioned civil agreements, how to do assessments to determine if one is fit to enter into civil agreements, and what are the legal ways in which a person can avail help to execute his/her civil rights even when affected by mental health issues.

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.