Roadmap to Indian psychiatry

Natural and human-made disaster and associated health outcomes among community-dwelling older adults in India: Findings from LASI, 2017-18

BACKGROUND

Droughts, flash floods, rail accidents, and riots are relatively regular occurrences for those living in many low- and middle-income countries like India. While such natural and human-made disasters put everyone in harm's way, their toll on specific segments of society-like older adults-is the heaviest. Therefore, in this study, we examine (1) the prevalence of natural and human-made disasters in India and (2) the association between natural and human-made disasters and several physical and mental health outcomes among older Indians.

METHODS

A cross-sectional study was conducted utilizing data come from the 2017-18 wave 1 of the nationally representative Longitudinal Ageing Study in India, comprising a sample of 29,333 older adults (14,120 males and 15,213 females) aged 60 years and above. Multivariate random intercept multilevel logistic regression analysis is used to examine the association between natural and human-made disasters and poor self-rated health, difficulty in activities of daily living, difficulty in instrumental activities of daily living, communicable diseases, non-communicable diseases, depressive symptoms, and psychiatric disorder.

RESULTS

Overall, 3.58% of older adults reported that they have encountered any type of natural or human-made disaster in the past five years. Compared to those who did not experience any (natural or human-made) disaster, older adults who experienced any disaster had a higher prevalence of poor self-rated health (33.4% vs 23.31%), difficulty in activities of daily living (33.94% vs 23.00%), difficulty in instrumental activities of daily living (60.09% vs 47.70%), communicable diseases (49.57% vs 25.86%), depressive symptoms (17.30% vs 8.06%) and psychiatric disorders (3.42% vs 2.78%). After adjusting for the selected variables and the contextual effect, the odds of poor self-rated health (1.64 [1.40, 1.92]), difficulty in activities of daily living and instrumental activities of daily living (1.89 [1.61, 2.21] and 1.63 [1.40, 1.89]), communicable and non-communicable diseases (2.12 [1.83, 2.46] and 1.38 [1.20, 1.60]), depressive symptoms and psychiatric disorder (1.67 [1.55, 2.05] and 1.52 [1.33, 2.18]) were significantly higher among older adults who experienced a natural or human-made disaster than their counterparts without such an experience.

CONCLUSIONS

Relative to their non-exposed counterparts, older Indians who survived natural or human-made disasters endured an inflated risk of poor self-rated health, functional difficulties, communicable and non-communicable diseases, depressive symptoms, and psychiatric disorders. As such, post-disaster efforts should be grounded in policies and programs that address disaster-related trauma and diseases and improve the functional, physical, and psychological facets of health among older disaster survivors.

The prevalence of depression among paramedical students and workers with highlights from the COVID-19 pandemic: A meta-analysis of prevalence

OBJECTIVE

To estimate the prevalence and risk factors of depression among paramedical workers/students.

METHOD

6205 paramedics (reported in 25 cross-sectional studies) were meta-analyzed after searching seven electronic databases. The main outcome was the prevalence of depression. Subgroup analyses were conducted based on year and country of investigation, pandemic status and wave, population type, and disease severity. Several risk factors were also examined (gender, marital status, and population type).

RESULTS

34% [95%CI: 26-43%] of paramedics have depression, mostly of the mild form [19%, 95%CI: 13-27%]. Depression was highest in India and Australia. Students [45%, 95%CI: 30-62%] were more vulnerable to depression than workers [29%, 95%CI: 18-40%]. No linear trend was observed for depression over the years. Depression was lower during the pandemic compared to the pre-pandemic period [25% vs. 39%] with similar rates across all pandemic waves. Male [MD = 1.40; 95%CI: 0.57: 2.23] and married paramedics [MD = -1.33, 95%CI: -2.04: -0.62] were significant predictors of depression; however, no significant difference in depression was noted between paramedics and non-paramedics [logOR = 0.08; 95%CI: -0.10: 0.25].

CONCLUSIONS

One in every three paramedics have depression, with higher rates among students and before the COVID-19 pandemic. Gender and marital status are risk factors of depression.

Prevalence of medical comorbidity in early onset versus late-onset depression in Vindhya region

BACKGROUND

Late-onset depression differs significantly from early-onset depression according to clinical features, physical comorbidities, cognitive impairment, and cerebrovascular abnormalities, which suggest that these might have differing etiopathological pathways toward the depressive phenotype.

AIM

The aim of the study was to identify comorbid physical disorders with late-onset depression.

METHODS

The present cross-sectional study was conducted in inpatients of the Department of Psychiatry during a period of 18 months. A study consisted of 60 patients of first depressive episode diagnosed using International Classification of Diseases-10 criteria, segregated 2 different groups of Early onset depression (between 40 and 65 years) and late-onset depression (LOD) (>65 years) with 30 patients each.

RESULTS

In LOD group, predominant comorbidities were hypertension 56.6%, cerebrovascular disease 36.6%, diabetes 33.3%, cardiovascular disease 23.3%, and anaemia 23.3%, followed by respiratory illnesses, arthritis, benign prostatic hyperplasia and cirrhosis. While, in early-onset depression group, common comorbidities were hypertension (13.3%), anemia (10%), arthritis (10%), and diabetes (6.6%).

CONCLUSIONS

Hypertension cerebrovascular disease, diabetes, and cardiovascular disease were the predominant comorbidities in late-onset as well as early onset depression.

Situational analysis of prevailing practices in the management of first-episode psychosis in Chennai, India

AIM

This paper aims to examine how existing mental health within the city of Chennai, India manages first-episode psychosis, to determine lacunae and barriers in providing effective early intervention and to make appropriate recommendations to improve the care of first-episode psychosis patients.

METHODS

Interviews were held with 15 health professionals to capture information on current practices and facilities available for the management of first-episode psychosis.

RESULTS

No specialized clinic or services were available for individuals with first-episode psychosis in Chennai, except one. Pharmacotherapy was the main treatment modality with psychological support to patients and families. Most common drugs used were Risperidone, Olanzapine, and Haloperidol in their recommended doses. General practitioners and paediatricians, due to inadequate training in mental health, referred patients with psychosis to mental health professionals.

CONCLUSIONS

Equipping the existing mental health services to manage FEP and training all health professionals on psychosis will improve FEP management in Chennai.

Public Attitudes Toward Psychiatric Hospitals: A Rural-Urban Comparative Public Survey in Odisha State, India

Background: Integration of psychiatric care with public health services and offering mental health care services to patients from lower socioeconomic status remains a global challenge. Scarcity of funds and professional workforce in psychiatric hospitals contribute to this situation. However, negative attitudes in the population are also a known impediment to patients seeking mental health services. This study aimed to assess the attitudes toward psychiatric hospitals among the urban and rural population in India. Subjects and Methods: The study was carried out amongst the general population in Odisha, India. The total sample (n = 988) includes 496 respondents from an urban-setting, and 492 respondents from rural parts of the district. Participants were selected by using simple random-sampling from the Asian Institute of Public Health (AIPH) data base. A standardized seven-item questionnaire was adopted, with responses indicated on a 5-point Likert-scale. Interviews were fully structured and conducted face-to-face. Results: Level of education (B = -0.192, ß = -0.320, p < 0.000) and urban-rural comparison (B = -0.272, ß = -0.189, p < 0.000) significantly influenced attitudes toward psychiatric hospitals. Gender, age, and religious beliefs did not show any significant effect on attitudes toward psychiatric hospitals. Individuals in rural areas and those with lower education levels showed more negative attitudes toward psychiatric hospitals. Conclusion: Negative attitudes toward psychiatric hospitals from those living in rural areas as well as those with lesser education may be reflective of the lack of availability, accessibility, affordability, and credibility of such mental health services. The Mental Health Care Act in India is a progressive legislation which might improve the situation of the provided services and, consequently, reduce negative attitudes in the years to come.

Participatory Workshop-Based Intervention for Better Preparedness and Awareness About Disaster Management Among Accredited Social Health Activists in India: A Brief Report

OBJECTIVES

The aim of this study was to evaluate the effectiveness of training programs in improving the knowledge about disaster management among Accredited Social Health Activists (ASHAs) in Mysuru, India.

METHODS

A quasi-experimental study was conducted among 40 ASHAs of 3 Primary Health Centers in Mysuru district. A 3-h disaster management training and workshop followed by a mock-drill was organized in each center. Knowledge about disaster preparedness and management was assessed before and 1 mo after the intervention using a questionnaire by interview method. The data obtained were entered into an MS Excel spreadsheet and analyzed using licensed SPSS 22 software.

RESULTS

The mean score obtained by the ASHAs in pretraining assessment was 37.2 ± 10.4. Improvement was evident in the knowledge and preparedness of ASHAs 1 mo after the training, which showed a mean score of 90.14 ± 5.05. This change in score was statistically significant with a P-value < 0.001 on performing a paired t-test.

CONCLUSION

Training programs with mock drills and hands-on activities are effective in improving the knowledge of frontline health workers about disaster management. We recommend such training to be organized in all public health facilities.

Frames of Mental Illness in an Indian Daily Newspaper

A qualitative framing analysis of a sample of stories on mental illness (N = 177) in The Times of India, India's largest-selling English language broadsheet newspaper, was conducted. Specifically, frames were examined for whether, and if so, how they challenged or perpetuated mental illness stigma. Two predominant frames were identified: people with mental illness are a danger to themselves and others and mental illness can be caused and treated in various ways. Frames had a mix of positive and negative aspects-some that challenged stigma and others that perpetuated it. For example, stories typically attributed mental illness to socioenvironmental, not biological determinants, reflecting a tension between traditional cultural and neurobiological conceptions of mental illness. Such framing could reduce stigma by placing responsibility for recovering from mental illness on the community, not on the individual. However, it could increase stigma by suggesting that mental disorders are not legitimate medical disorders. Also, people with mental illness were rarely quoted, thereby perpetuating stigma by implying, for example, that they are not capable of being interviewed. This study contributes to understanding of how stigma and anti-stigma frames about mental illness are constructed by media in a non-Western sociocultural context. The findings have implications for news coverage of mental illness as well as for the design of anti-stigma interventions in India.

Telepsychiatry in India - Where Do We Stand? A Comparative Review between Global and Indian Telepsychiatry Programs

A wide discrepancy exists in India between the existing mental healthcare repertoire and the alarmingly high burden of individuals requiring immediate attention from requisite mental healthcare services. Providing equitable mental healthcare across a vast country characterized by profound cultural variations and territorial caveats has remained a major public health concern. Against this gloomy backdrop, the emergence of distant communications technology offers solace and optimism as an ingenious approach to bridge the existing gap between clients and mental health professionals. Using inexpensive equipment and basic technical knowhow, telepsychiatry expands the scope of the discipline to distant and hazy suburbs and villages from its urban centers of excellence. The current academic endeavor intends to perform a systematic review of relevant literature from India as well as from other countries. The various models of telepsychiatry-both asynchronous and synchronous models-in practice have been elaborated on with a focus on effectiveness, feasibility and acceptability of this latest modality. A sincere attempt to chronicle the remarkable journey of telepsychiatry in India, beginning in the dawn of the 21^st century to the current Indian scenario, has been made. The legal and ethical issues, along with a few words of caution and contemplation, have been briefly touched on. A set of recommendations has been provided with the hope that policy makers and administrators in the domain of mental health may benefit from them. It is anticipated that telepsychiatry will be adequately utilized in India to tackle the raging menace of inadequate mental healthcare services.

Attitude towards psychiatrists: A comparison between two metropolitan cities in India

BACKGROUND

Few patients in need of mental health care have access to psychiatric care in low and middle income countries. Public attitudes towards psychiatrists have not been adequately studied in most developing countries and especially in India, where on average one trained psychiatrist is available for 300,000 people. The aim of our study was to explore attitudes towards psychiatrists in the general population in two Indian metropolitan cities (Chennai and Kolkata) and to identify factors that could influence these attitudes.

SUBJECTS AND METHODS

Explorative surveys in the context of public attitudes towards psychiatrists were conducted in a convenience sample from the general population in Chennai (n=166) and Kolkata (n=158). Sampling was balanced for age, gender and school education.

RESULTS

Comparing the two samples using a multivariate analysis, we found more negative attitudes towards psychiatrists in Chennai compared to Kolkata (p<0.0001). Negative attitudes correlated with lower education levels (p<0.001) and stronger religious beliefs (p<0.05) in both cities.

CONCLUSION

Attitudes towards psychiatrists differed widely between two large metropolitan cities in India. In line with previous studies, negative attitudes correlated with lower level of education and stronger religious beliefs across both cities. Future studies may identify finer cultural and social factors that play an important role in attitudes towards psychiatrists in a diverse country like India.

Increasing access to Cognitive Behaviour Therapy in Low and Middle Income Countries: A strategic framework

Cognitive Behaviour Therapy has been demonstrated to be an effective intervention in outpatient and inpatient settings for a wide range of presenting mental health problems including depression, Obsessive Compulsive Disorder, Post traumatic Stress Disorder, Social Anxiety Disorder, Panic Disorder and Somatorform Disorder. There is likely to be an unmet need for this therapeutic approach in most Low and Middle Income Countries (LMIC). However, the training of therapists to deliver this intervention has historically been a lengthy and expensive process, with already highly trained staff such as psychiatrists and psychologists undertaking additional training of up to one year duration in order to develop expertise in this area. This paper proposes that a model where training, supervision, leadership and service evaluation is provided by a small number of highly trained staff to front-line non-specialist staff who will then deliver manualised therapy. These front-line staff may also be conceptualised as part of a stepped care model where self-help and manualised therapy approaches are used in the first instance. Where patient functioning does not improve there is then the possibility of being stepped-up for treatment by a more specialised and highly trained therapist. This approach may help in meeting the huge mental health treatment gap in LMIC. This paper also suggests that lessons learnt from the dissemination of behaviourally informed parenting interventions internationally can be applied to the dissemination of this therapeutic approach.

Developing cognitive behaviour therapy training in India: Using the Kolb learning cycle to address challenges in applying transcultural models of mental health and mental health training

Although mental health workers in India across all major professional groups have identified an unmet need for training in cognitive behaviour therapy (CBT), the uncritical export of models of mental health, therapy provision and training to low- and middle-income countries is a problematic process. This paper describes the context for the first stand-alone CBT training programme in India, based in Chennai. This paper includes an evaluation of the first phase of the training and information from trainees regarding the quality and applicability of the training to their working context. The paper provides an overview of some of the critiques that are pertinent to this process and considers the way that the Kolb learning cycle can be used as a framework within training to go some way to addressing these difficulties.

Enhancing mental health literacy in India to reduce stigma: the fountainhead to improve help-seeking behaviour

Purpose

– Lack of understanding around mental illness and stigma are an overwhelming barrier in help-seeking behaviour for mental health concerns. The purpose of this paper is to examine mental health literacy and social attitudes as instrumental factors in building capacity of the demand-side to support and access mental health care at the community level in India.

Design/methodology/approach

– Knowledge, Attitude and Practice surveys were administered to 521 persons from the general population, distributed equally in the age range of 15-60 years. The study included 52 respondents per district from ten districts across five states in India, namely Andhra Pradesh, Assam, Delhi, Gujarat and Uttar Pradesh. The responses were collected and analysed thematically, keeping in mind the relevance of these findings as contributors to knowledge of mental health and to the construct of stigma.

Findings

– Pervasive socio-cultural factors, especially stigma inhibit access to basic mental health information and care, despite knowledge that mental illness is treatable. Degrading treatment, loss of personal liberty and social exclusion, i.e. compromised human rights at the community level are widespread. Self-reported attitudes when encountering a person with mental illness show that respondents act out of fear and are guided by misinformation and myths. Extant knowledge on mental health is attributed predominantly to informal networks, as a potential resource to be strengthened.

Practical implications

– Realising mental health care, including help-seeking behaviour calls for greater knowledge-sharing, sensitisation and community engagement.

Originality/value

– This paper fulfils an identified need to study current levels of mental health literacy and underlying perceptions that contribute to the persistent treatment gap.

Identifying the 'mentally disabled' in the community: How much more is to be imparted to the internees in training?

BACKGROUND

Studies have been conducted on the skills of physicians in general hospitals in identifying mental disorders,but there are no studies assessing the proficiency of internees in identifying mental disorders.

AIM

To confirm the diagnosis of the cases identified by 40 internees in the community as 'mentally disabled'.

MATERIALS AND METHODS

Of 15,583 people,29 were identified in the community by the internees as 'mentally disabled'. This was followed by home visits to the houses of these 29 individuals conducted by two qualified psychiatrists and one clinical psychologist, and these cases were screened for their psychiatric status using MINI Plus.

RESULTS

Most of the cases identified by internees as having 'mental disability' were cases of mental retardation and the others were mood and psychotic disorders and epilepsy. Cases of mental retardation and mental disorders other than those identified by the internees could also be identified while visiting the respective geographical areas.

CONCLUSIONS

There is a need to hone the skills of the medical students during the course of their training in identifying cases of mental retardation, severe as well as minor psychiatric disorders, as a part of their training. There is also a need for the use of structured scales for the same.

Sexual variation in India: A view from the west

Sexual variation has been reported across cultures for millennia. Sexual variation deals with those facets of sexual behavior which are not necessarily pathological. It is any given culture that defines what is abnormal and what is deviant. In scriptures, literature and poetry in India same sex love has been described and explained in a number of ways. In this paper we highlight homosexual behavior and the role of hijras in the Indian society, among other variations. These are not mental illnesses and these individuals are not mentally ill. Hence the role of psychiatry and psychiatrists has to be re-evaluated. Attitudes of the society and the individual clinicians may stigmatize these individuals and their behavior patterns. Indian psychiatry in recent times has made some progress in this field in challenging attitudes, but more needs to be done in the 21(st) century. We review the evidence and the existing literature.

Indian Journal of Psychiatry and psychiatric research in India: Past, Present and Future

Commendable work has been done in psychiatric research in India as it moves in tandem with contemporary trends abroad. Indian Journal of Psychiatry (IJP), as its flag-ship publication, has mirrored this trend faithfully down the decades. Stalwarts and icons of Indian psychiatry have set Indian research firmly on this course. A systematic appraisal of psychiatric research in India shows that most work is replicative, some of it corrective at the local level, and very little that is original and corrective at the international level. Opinion and policy makers, including IJP and research departments at colleges and universities, must endeavor to steer the course towards trend-setting and original work emanating from India, even as we do not neglect replicative work, of which we are masters.

Psychiatrists and neuroscientists of Indian origin in Canada: Glimpses

Psychiatrists of Indian origin are popular in Canada, being firmly rooted in the Canadian mental health system, and they have been making considerable contributions internationally. The Indian Psychiatric Society has long been collaborating with and inviting contributions from overseas Indian psychiatrists, particularly those in academics, and this collaboration has fructified well. There are several different challenges these psychiatrists have had to face in their own specialty work, with having to adjust to a new culture, new ways of living, and new ways of work. Our colleagues of Indian origin have demonstrated excellence in almost all fields of mental health and neurosciences. There are many popular teachers, outstanding researchers, and psychiatrists in community practice and community development. The Early Psychosis Program, Mood and Anxiety Program, Perinatal Psychiatry, Women's Mental Health, and Postpartum Mental Health are some of their key areas of research. Our basic scientists are involved in experimental design, neurochemistry, imaging, and genetics, where they have made their mark with acclaim. This article highlights some of the achievements of a few members and is by no means completely representative of the entire work that psychiatrists of Indian origin are doing in Canada, providing readers with a glimpse of our labors away from home.

Indian research on disaster and mental health

The primary source for this annotation on disaster mental health research is the Indian Journal of Psychiatry. Key words like disasters, earthquake, cyclone, tsunami and flood were searched from its electronic database and relevant articles are discussed. The cross-referenced articles and relevant researches conducted on disasters in India which are published elsewhere were the secondary sources of information. There have been many epidemiological studies and only a few interventional studies on disasters in India. Prevalence figures of psychiatric disorders varied considerably across studies, secondary to nature and severity of disaster, degree of loss, support available and probably also due to the study methodology. Suggestions for intervention included pre-disaster planning, training of disaster workers, utilization of community-level volunteers as counselors, and strengthening existing individual, social and spiritual coping strategies. There is a need for more longitudinal follow-up studies and interventional studies.

An overview of Indian research in depression

Depression as a disorder has always been a focus of attention of researchers in India. Over the last 50-60 years, large number of studies has been published from India addressing various aspects of this commonly prevalent disorder. The various aspects studied included epidemiology, demographic and psychosocial risk factor, neurobiology, symptomatology, comorbidity, assessment and diagnosis, impact of depression, treatment related issues and prevention of depression in addition to the efficacy and tolerability of various antidepressants. Here, we review data on various aspects of depression, originating from India.