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.

MCI’s VISION 2015 and PG medical selection: continuing to produce square pegs for round holes.

The need for better methods of selection for postgraduate (PG) medical seats in different specialties has never been more keenly felt than in the current scenario. Multiple entrance exams, management quota and paid seats, the urgency to get into a PG seat at any cost and the mushrooming of PG entrance exam coaching centres have added to the angst and woes of medical students. Currently the Indian medical education system is one of the largest in the world with around 250 colleges fully recognised by the Medical Council of India (MCI).

Healthcare reform in the USA, 2010: the rocky road ahead.

Historic legislation for healthcare reform in the United States was enacted in March 2010. Reforms in medical practice, payment for services, and access to care and insurance will be introduced by complex processes over time through 2019. The overriding goals of healthcare reform are cost containment and guaranteeing access to all Americans. The contentious political struggle that preceded the legislation is emblematic of the continuous struggle in American society to define who is worthy of services. Understanding the value framework for social and welfare provisions in American society is crucial to making sense of the piecemeal policymaking characteristic of the development of healthcare over the past 50 years. Here some highlights of the reform and the complex organisation of American healthcare are discussed.

Objective standardized clinical assessment with feedback: Adapting the objective structured clinical examination for postgraduate psychiatry training in India.

Background: The objective structured clinical examination (OSCE) is used commonly for assessment of psychiatry trainees but has been used less for teaching. Aim and Setting: This study describes the adaptation of the OSCE method for training purposes in a postgraduate psychiatry training center in India and the initial findings with regard to trainee performance. Materials and Methods : The adapted method was called the objective structured clinical assessment with feedback (OSCAF). The adaptation included several steps - modifying existing OSCE patterns for language and cultural appropriateness, using supervised roleplaying instead of standardized or simulated patients and evolving an assessment method (14-item checklist) that would generate feedback. This exercise was conducted in front of a group of multidisciplinary peers and supervisors. Statistical Analysis: Descriptive statistics and ANOVA were used. Results: Analysis of the performance based on the 14-item checklist assessing common elements of any patient-related interaction in 34 different OSCAF tasks indicated the following: less-than-satisfactory (<75%) performances in the following areas - assuring confidentiality (73.5%), assessing comfort (62%), summarizing (60%), closure (62%) and checking whether the 'patient' had understood what was being communicated (42%). Based on the nature of clinical situations, performances on some specific and difficult OSCAF situations were found to be inadequate and indicated need for further training. Conclusions: We have been able to demonstrate OSCAF to be a convenient, cost-effective training method in psychiatry, with limited demands on resources; however, further refinements in ratings and feedback methods and studies on effectiveness may enhance its utility.

Should mental health assessments be integral to domestic violence research?

Research on sensitive issues such as abuse and violence in vulnerable populations poses several ethical dilemmas. An important aspect is the impact of such enquiries on one's mental health. This paper discusses specific ethical issues related to mental health based on violence research conducted and reviewed by the authors. Research on violence among women includes the possibility that some revelations are occurring for the first time and are likely to be emotionally charged. Further, the very act of disclosure may involve emotional risks for the respondent. Psychological distress may be present prior to, during, or following the study. Hence assessing mental health parameters becomes essential and integral to research of this nature. Several issues in methodology are also important in mitigating the level of distress. Research on sensitive issues should either use measures developed in the same culture or those with adequate adaptation. The order of questions, language and method of termination of the interview may often make a difference to its psychological impact. While focus group discussions and semi structured interview schedules are most suited, questionnaires with a less structured and rigid approach may also be used. Preludes may be introduced to facilitate transition between different sections of an interview schedule and to provide a rationale for further enquiry. Obtaining informed consent in violence research should be a process rather than a one-time formality. Reports of adverse events are likely in violence research and hence such studies must include mental health intervention, ongoing follow up, documentation and appropriate referral services. Finally, since the researcher and the subject of the research are both affected in a study of this nature, adequate sensitisation, ongoing training and supervision of research staff are essential. Based on findings from ongoing research on violence and from review of other studies done in India, the paper will focus on best practices in addressing mental health issues in domestic violence research.

A review of the ethics in research on child abuse.

Research on violence and abuse, particularly involving vulnerable groups such as women and children, has many ethical ramifications. There are few published reports in India on ethical guidelines and standards in this area. This paper reviews Child Abuse: India 2007, a study conducted by the ministry of women and child development, government of India. The review highlights the need for conducting an ethical inquiry in this area. Certain concerns about the conduct of the study are raised. Core ethical issues pertaining to consent and refusal, risk and benefit, effects of the study process on the researcher and the researched and the reporting of adverse events are discussed. The ethical implications of the study and ethical responsibilities of the researcher are emphasised.

HIV & psychiatric disorders.

HIV infection and psychiatric disorders have a complex relationship. Being HIV infected could result in psychiatric disorders as a psychological consequence of the infection or because of the effect of the HIV virus on the brain. Disorders may be as varied as depression, post-traumatic stress disorders, AIDS phobias, grief and the whole gamut of cognitive disorders. In addition, several psychiatric conditions may predispose individuals to acquiring HIV infection as a consequence of their influence on behaviour. There is also strong evidence of the relationship of substance use disorders and severe mental illnesses with HIV infection. HIV related psychiatric disorders also offer a challenge to clinicians in issues of differential diagnosis and management. Majority of the work in India has focused on substance use and HIV, and to a lesser extent on the psychiatric effects of HIV infection. Given the magnitude of the problem in the country and the multiple physical and psychological stressors that persons with HIV face in India, more research is needed.