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.

Non-Medical Use of Prescription Drugs in Bangalore, India.

Background: Non-medical prescription drug use is an ongoing problem in India; however, there is paucity of literature in the Indian population. Objective: The objective of the present study is to explore the non-medical use of prescription medicines in urban Bangalore, South India (N = 717). Materials and Methods: Participants were recruited using a mall-intercept approach, wherein they were intercepted in 5 randomly selected shopping malls, and interviewed on their use of prescription medicines. Results: The mean age of the participants was 28 years (S.D. 5). The nonmedical use of different prescription medicine classes over the past 12 months was as follows: anti-infl ammatories and analgesics (26%), opioids (17%), antibiotics (13%), and sedatives (12%). The majority reported “use without prescription,” while “use in ways other than as prescribed” was also reported. In all cases, chemist shops were the main source of obtaining the drugs non-medically. In multivariate logistic regression analyses, non-medical use was found to be signifi cantly associated with participants’ baseline characteristics like gender, education, current employment status, and marital status. Sixty-fi ve percent stated that although “doctor’s prescription is not required for common complaints, we can decide ourselves,” while 60% stated, “it’s okay to deviate from a prescription as needed.” One hundred percent said that “using prescription medicines is more socially acceptable, and safer, compared to alcohol or illicit drugs.” Conclusion: These fi ndings underscore the need for considering various contextual factors in tailoring preventive interventions for reducing non-medical use of prescription drugs.

Quantitation of ethyl glucuronide in serum & urine by gas chromatography - mass spectrometry.

Background & objectives: Alcohol misuse has now become a serious public health problem and early intervention is important in minimizing the harm. Biochemical markers of recent and high levels of alcohol consumption can play an important role in providing feedback regarding the health consequences of alcohol misuse. Existing markers are not sensitive to recent consumption and in detecting early relapse. Ethyl glucuronide (EtG), a phase-II metabolite of ethanol is a promising marker of recent alcohol use and can be detected in body fluids. In this study an analytical technique for quantitation of EtG in body fluids using solid-phase extraction (SPE) and gas chromatography (GC) with mass spectrometric detection (MS) was developed and validated. Methods: De-proteinization of serum and urine samples was done with perchloric acid and hydrochloric acid, respectively. Serum samples were passed through phospholipids removal cartridges for further clean up. EtG was isolated using amino propyl solid phase extraction columns. Chromatographic separation was achieved by gas chromatography with mass spectrometry. Results: Limit of detection and limit of quantitation were 50 and 150 ng/ml for urine and 80 and 210 ng/ml for serum, respectively. Signal to noise ratio was 3:1, mean absolute recovery was 80-85 per cent. Significant correlation was obtained between breath alcohol and serum EtG levels (r=0.853) and urine EtG and time since last abuse (r = -0.903) in clinical samples. Interpretation & conclusions: In the absence of other standardized techniques to quantitate EtG in biological samples, this gc -ms method was found to have high throughput and was sensitive and specific.

Psychiatric advance directives: potential challenges in India.

he advance directive is a statement of an individual’s preference for future treatment. The concept initially evolved in the context of end-of-life treatment decision making. Subsequently, in some countries, advance directives have been promoted in the care and treatment of people with serious mental disorders. They have recently been endorsed by the United Nations Convention for the Rights of Persons with Disability. In India, the legal framework related to the care of persons with mental illness is currently being reappraised, and significant changes are being contemplated. Thus, this is an appropriate time to review the existing evidence on psychiatric advance directives and examine the potential challenges involved in making them legally binding.

Initiating tobacco cessation services in India: Challenges and opportunities.

Background: Tobacco use contributes significantly to the diseases burden in India. Very few tobacco users spontaneously quit. Therefore, beginning 2002, a network of 19 tobacco cessation clinics (TCCs) was set up over a period of time to study the feasibility of establishing tobacco cessation services. Methods: Review of the process and operational aspects of setting up TCCs was carried out by evaluation of the records of TCCs in India. Baseline and follow-up information was recorded on a pre-designed form. Results: During a five-year period, 34 741 subjects attended the TCCs. Baseline information was recorded in 23 320 cases. The clients were predominantly (92.5%) above 20 years, married (74.1%) and males (92.2%). All of them received simple tips for quitting tobacco; 68.9% received behavioural counselling for relapse prevention and 31% were prescribed adjunct medication. At six-week follow-up, 3255 (14%) of the tobacco users had quit and 5187 (22%) had reduced tobacco use by more than 50%. Data for three, three-monthly follow-ups was available for 12 813 patients. In this group, 26% had either quit or significantly reduced tobacco use at first follow-up (three-months), 21% at the second (six-months) and 18% at the third follow-up (nine-months) had done so. Conclusions: It is feasible to set up effective tobacco cessation clinics in developing countries. Integration of these services into the health care delivery system still remains a challenge.

Qualitative high performance thin layer chromatography (HPTLC) analysis of cannabinoids in urine samples of Cannabis abusers.

Background & objectives: Cannabis is one of the most commonly abused drugs worldwide. There is a distinct clinical correlation between cannabis abuse and mental disorders. However, it is essential to establish cannabis intake in the abusers in order to establish causality between cannabis and psychiatric illness. The limitations of current detection methods using commercial cassettes prompted us to standardize the method of extraction and detection of cannabinoids in the urine samples of cannabis abusers attending a de-addiction centre in south India. Methods: In this study, diagnostic tests on 102 male patients suspected with cannabis abuse were done. Liquid-liquid extraction of cannabinoids from urine was done and screened by Duquenois-Levine, fast blue B salt and p-dimethylaminobenzaldehyde (p-DMAB) tests. All the results were confirmed by high performance thin layer chromatography (HPTLC). Samples were considered positive for cannabis based on the positive indication in colour test and by detection of 11-nor-Δ9 tetrahydrocannabinol-9-carboxylic acid (THC-COOH) on HPTLC. Results: Based on the colour tests and HPTLC, cannabis abuse was detected in 64 of 102 patients tested. HPTLC method was found to be sensitive for detection and possible quantitation of THC-COOH. Interpretation & conclusion: We report the standardization and utility of cannabinoid extraction, screening and detection by HPTLC in the urine samples of cannabis abusers. The HPTLC method was found to be high throughput, sensitive, reproducible and cost-effective compared to commercial kits.

Fetal alcohol spectrum disorder.

BACKGROUND: Maternal alcohol use during pregnancy leads to fetal alcohol spectrum disorder (FASD) in their children. FASD is characterized by typical facial features, growth retardation, intellectual dysfunction and behavioral problems. JUSTIFICATION: Alcohol is neurotoxic to the brain during the developmental stage. Behavioral problems in children with FASD start at an early age and progress to adulthood. It is an important preventable cause of intellectual dysfunction and behavioral problems. This article reviews current prevalence, clinical features, pathogenesis and differential diagnosis of FASD. It also highlights the need for physicians to be aware of this condition. SEARCH STRATEGY: Articles were searched on the internet using fetal alcohol syndrome, fetal alcohol spectrum disorders, women and alcohol. Following links were used to locate journals; EBSCO, OVID, Science Direct, PubMed and NIAAA. MAIN CONCLUSIONS: Alcohol consumption during pregnancy can lead to a spectrum of deficits. Though physical features are essential to make the diagnosis of FAS, it is important to note that neurocognitive and behavioural deficits can be present in the absence of physical features (alcohol related neurodevelopmental disorder or ARND). Because there is no known safe amount of alcohol consumption during pregnancy, abstinence from alcohol for women who are pregnant or planning a pregnancy must be strongly advised.